International Cardiovascular Disease Prevention case studies

October 2018
Report and case studies
This publication has been based on information and data provided by a number of third
parties. While care was taken in the preparation of the information in this report and every
effort has been made to ensure the information is accurate and up-to-date, SPH accepts no
responsibility for gaps or limitations in the information.

Acknowledgements

With acknowledgment and thanks to all those who provided information or material and who
participated in interviews.
Contents

Executive Summary ................................................................................1

Introduction ........................................................................................... 12
1 Aims and objectives .......................................................................12
2 Methods ......................................................................................... 12
3 Background and context of cardiovascular disease prevention in
England.......................................................................................... 15
4 Strategies for CVD prevention in England ......................................19
5 Case studies .................................................................................. 25
Australia: Coaching patients On Achieving Cardiovascular Health (COACH) ............... 25
Finland: DEHKO and One Life ..................................................................................... 26
France: ESCAPE ......................................................................................................... 28
The Netherlands: Vascular risk management ............................................................... 28
Canada: The Cardiovascular Health Awareness Program (CHAP) .............................. 30
Japan: Healthy Japan 21 ............................................................................................. 31
United States: Franklin County..................................................................................... 32
United States: New Ulm Heart Beats Back................................................................... 34
Canada: Hypertension Canada .................................................................................... 35
United States: Million Hearts ........................................................................................ 37
Key features of a successful CVD programme ........................................................... 39

6 Discussion ..................................................................................... 42
Whole population approach to raising awareness and changing lifestyle ..................... 42
Detection of people with high risk of CVD .................................................................... 43
Prevention for people at high risk of a first or subsequent CVD event or diagnosis. ..... 45

7 Conclusion ..................................................................................... 46
8 Appendices .................................................................................... 48
Appendix 1: Framework for information gathered for CVD prevention case studies from
interviews and programme documentation ................................................................. 48
Appendix 2: Socio ecological model and the influencers on health status with examples
of policy, strategy, guidance and media campaigns used in England to promote CVD
prevention .................................................................................................................. 50
Appendix 3: Australia COACH Programme ................................................................ 58
 Appendix 4: Finland DEHKO And One Life................................................................. 69
Appendix 5: France ESCAPE Trial ............................................................................. 79
Appendix 6: Netherlands Vascular Risk ...................................................................... 88
Appendix 7: Canada CHAP Program.......................................................................... 96
Appendix 8: Healthy Japan 21 .................................................................................. 106
Appendix 9: Franklin County CVD Risk Reduction ................................................... 115
Appendix 10: USA HONU Project ............................................................................. 123
Appendix 11: Hypertension Canada ......................................................................... 133
Appendix 12: Hypertension Canada ......................................................................... 143

9 References .................................................................................. 154

Executive Summary
Cardiovascular disease (CVD) affects around seven million people in the United Kingdom
(UK) and is a significant cause of disability and death, affecting individuals, families and
communities. CVD is responsible for one in four premature deaths in the UK and was
responsible for 26% of all deaths (129,147) in England in 2015.1 Healthcare costs in the UK
associated with CVD are estimated to be about £8.96 billion and non-healthcare costs
estimated at about £4.04 billion (Wilkins et al 2017).2 There are a number of different
physiological and behavioural risk factors for CVD, including smoking, high cholesterol, high
blood pressure, poor diet, harmful drinking and physical inactivity. It is also linked to a range
of environmental and social factors, including air pollution and financial inequalities.

Solutions for Public Health (SPH) was commissioned by the British Heart Foundation (BHF)
and Public Health England (PHE) to identify and describe cardiovascular disease prevention
programmes successfully implemented in countries outside the UK. SPH developed case
studies for 10 of these programmes that illustrate approaches that may be applicable and
effective within the UK. This report sets out how SPH undertook this project, the current
context in England and the case studies that emerged from the information gathering
process.

The purpose of this project is to:

 Identify, describe and critique a series of cardiovascular disease (CVD) prevention
programmes that are, or have been, implemented outside the UK
 Make recommendations for implementation of effective CVD prevention programmes
in England and the UK
 Provide background and context of current CVD prevention programmes in England,
within which CVD prevention programmes from elsewhere may be implemented in
this country.

The programmes identified that were developed into case studies were a mix of prevention
approaches, some were single interventions and others were programmes with multiple
initiatives. They were all multifaceted in that they targeted a range of modifiable CVD risk
factors including those that would benefit from lifestyle change and/or optimisation of
medical management. Some programmes also described in detail how people with
undetected high risk of CVD were identified.

Four of the case studies focus on people with CVD or a high risk of CVD, with risk factors
such as, atrial fibrillation, hypertension, hypercholesterolaemia and diabetes. Those with
current CVD or a high risk of CVD are offered interventions to reduce their risk with the aim
of averting further morbidity and impact on health services. A further four case studies are
programmes with a combination of prevention approaches encompassing both prevention of
developing, and amelioration of, CVD risk factors across populations. These programmes
typically comprise multiple small initiatives under one programme umbrella.

Two cases studies are national initiatives with a core aim to improve the detection and
effective management of people at risk of CVD. This is achieved through building research
capacity, collaborating with stakeholders, education of public and professionals, developing
guidelines and promoting evidence based activities in health services and the community.

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Table1: Case studies

Table 1A Australia: Coaching patients On Achieving Cardiovascular Health (COACH)

The COACH Program® (Coaching patients On Achieving Cardiovascular Health) focuses on increasing the engagement of individuals in understanding and
improving their own health by understanding how lifestyle impacts on CVD risk and identifying any treatment gaps in the management of conditions. The
intervention consists of coaching sessions for patients by trained nurses by phone over a minimum of three sessions.

Outcomes

Change in patient characteristics during and after the trial

Before After(6 18 months
months)
Percentage of patients achieving the total cholesterol target 27% 57% 52%
Percentage of patients undertaking physical activity 70% 94% 92%
Percentage not smoking 82% 94.5% 94.5%
Change in service outcomes at four year follow up

Activity Reduction (%)

Any-cause hospital admissions 16%

Any-cause hospital bed days 20%

Cardiac bed days 15%

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Table 1B Finland: DEHKO and One Life

DEHKO was launched in Finland as part of the Finnish National Diabetes Programme (FIN D2D), from 2000 to 2010 and aimed to improve self care and
prevent and reduce complications from type 2 diabetes. From 2011, the DEHKO programme expanded to include raising awareness and reducing risk of non
communicable diseases with common risk factors including cardiovascular disease (CVD), dementia, chronic obstructive pulmonary disease (COPD) and
type 2 diabetes. This included using a brief screening tool followed by an in depth health check up and education/motivational individual and group sessions
for those at high risk of CVD. ‘One Life’ is supported by a collaboration of the Finnish Diabetes, Brain and Heart Associations and focuses on supporting
people to make lifestyle changes to improve modifiable risk factors.

Outcomes

Population awareness of FIN-D2D Men Women

Awareness of national FIN-D2D within pilot area 25% 48%
Awareness of national FIN-2D2 outside of pilot area 20% 36%
For those with high risk of CVD at 12 months following intervention
Increase in reported physical activity 4.1% 3.8%
Improved dietary pattern 39.3% 39.2%
Increase in physical activity and improved dietary pattern 9.6% 14.2%
No lifestyle change 47% 42.7%
Reduction in 10 year risk for CVD event for people who reported change in physical activity and dietary 3.5% 1.5%
pattern
Change in 10 year risk for CVD event for people who reported no change in physical activity and dietary 0.15%* -0.43%^
pattern
*p<0.001 between groups compared with men who made changes to diet and physical activity levels and
those who did not
^ p=0.027 between groups compared with women who made changes to diet and physical activity levels
and those who did not.

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Table 1C France: ESCAPE

ESCAPE was designed to show whether a multifaceted intervention, aimed at general practitioners (GPs), could significantly increase the proportion of
hypertensive patients at high risk of cardiovascular disease (CVD) who achieved all their recommended therapeutic targets. This involved one day of GP
training and support to ensure patients were managed according to guidelines and followed up. A trial with an intervention group and no intervention group
measured the effect.

Outcomes

Comparisons at 2 years between intervention group and no intervention group Odds ratio (95% P value
confidence interval)
Patients achieving all their therapeutic targets compared with no intervention 1.89(1.09 to 3.27) p = 0.02
Patients achieving their blood pressure targets compared with no intervention 2.03(1.44 to 2.88) p < 0.0001
Difference in blood
pressure
Additional decrease in systolic blood pressure in intervention group compared with 4.8mmHg p < 0.0001
control
Additional decrease in diastolic blood pressures in intervention group compared with 1.9mmHg P<0.0001
control

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Table 1D The Netherlands: Vascular risk management

This programme was designed to improve and add to standard nurse-led vascular risk factor management of patients with the addition of web based support
focused on lifestyle change and adherence to medication following a CVD event.

Outcomes

Key outcomes at 12 months Percentage difference between groups (95% P value

confidence intervals)
Patients who quit smoking at 12 months 7.7(0.4 to 14.9) p=0.038
Patients reaching the low density lipoprotein goal 18.4%(5.9 to 30.9) p=0.004
Relative change in Framingham risk score of the intervention -8%(-18 to 2) ns
group compared to the usual care group

Table 1E Canada: The Cardiovascular Health Awareness Program (CHAP)

CHAP is a community based model of cardiovascular disease (CVD) prevention which has been used in a range of different communities. It encourages
people to become more aware of their cardiovascular risk and to acquire self-management skills. Increased detection of people at high risk of developing
CVD results in referral and the opportunity to manage the condition medically.

Outcomes
Longitudinal study of 13,596 people in 22 communities over 18 Baseline mean 18 months follow up
months
People attending ≥2 CHAP sessions improvement in blood pressure 142/78mmHg 123/69 mmHg
Rate ratio(95% CI) P value
Reduction in rate of acute myocardial infarctions 0.87(0.79 to 0.97) p=0.008
Reduction in congestive heart failure 0.90(0.81 to 0.99) p=0.029
No change in rate of stroke 0.99(0.88 to 1.12) p=0.89
No change in all cause mortality 0.98(0.92 to 1.03) p=0.38
No change in hospital death 0.86(0.73 to 1.01) p=0.06

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Table 1F Japan: Healthy Japan 21

Japan has embarked on a national health policy change to prevent lifestyle-related diseases, including cardiovascular disease (CVD) and diabetes. Following
the detection of high CVD risk (via the annual health check up) people are invited to participate in individual or group sessions to motivate them to reduce
their risk of metabolic syndrome and CVD.

Outcomes
Intervention No intervention P value
Waist circumference (WC) - clinically relevant (>5%) reduction - 21.4% 16.1% P<0.001
proportion(%) of participants at 3 years
BMI - clinically relevant(>5%) reduction - proportion(%) 17.6% 13.6% P<0.001
participants at 3 years
Reversal of metabolic syndrome – number of participants 47% 41.5% P<0.001
Reductions in systolic blood pressure (mmHg) -1.15mmHg -0.72mmHg
Reductions in diastolic BP -0.97mmHg -0.64mmHg
Odds ratio(95% confidence interval)
>5% reduction in WC intervention vs no intervention group 1.33(1.31 to 1.36) p<0.001
>5% reduction in BMI intervention vs no intervention n group 1.36(1.33 to 1.38) p<0.001
Reversal of metabolic syndrome 1.31(1.29 to 1.33) p<0.001

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Table 1G United States: Franklin County

This programme was an integrated, community-wide comprehensive cardiovascular risk reduction programme started in 1970 with a 40-year follow-up
assessing the impact of risk factor improvements on reductions in morbidity and mortality. The initial focus was on hypertension detection and management
but over the years broadened to encompass other CVD risk factors.

Outcomes
Outcome
From 1994-2006 reduction in Franklin County’s hospitalisation rate Observed vs expected difference -17
discharges per 1,000 population
Reductions in total in and out of area hospital charges for Franklin County $5,450,362 (£3,919,300) per annum
residents per year due to drop in hospitalisation rate

From 1974/75 to 1977/8 increase in proportion of people with treated and Absolute increase of 24.7%
controlled hypertension
From 1986 to 2009 increase in the proportion of people with treated and Absolute increase of 28.5%
controlled cholesterol levels
Smoking quit rates (ever smokers who report they have quit) with Franklin Improved from 48.5% in 1994-5 to 69.5% in
County quit rates significantly higher than those seen in Maine and the US 2006-10

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Table 1H United States: New Ulm Heart beats back (HONU)

New Ulm is a small community of 17,000 people and local health organisations were keen to track the cardiovascular health of the population before and
during the implementation of community wide interventions. There were individual, family and organisational and community level interventions implemented
in order to influence behaviour and reduce modifiable cardiovascular disease (CVD) risk factors.

Outcomes
Measure 2008-9 2010-11 2012-13
Blood pressure at goal* 79.3% 82.3% 86.4%
On blood pressure medication* 41.8% 43.5% 44.0%
Low-density lipoprotein at goal* 68.9% 72.3% 71.1%
High-density lipoprotein at goal 63.8% 59.0% 58.0%
Cholesterol at goal* 59.2% 64.2% 64.1%
Triglycerides at goal* 66.3% 68.7% 70.2%
On lipid medication* 25.3% 27.7% 29.1%
Not obese 56.0% 55.5% 55.1%
ǂ
Fasting glucose at goal 46.9% 49.7% 48.2%
Smoking 11.3% 12.6% 13.6%
ASCVD 10-year risk score <7.5% 27.8% 28.9% 27.5%

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Table 1I Canada: Hypertension Canada

Hypertension Canada was formed in 2010 from the merger of the Canadian Hypertension Society, the Canadian Hypertension Education Program and Blood
Pressure Canada. The main goal of this national initiative is to ensure that Canada is effective in controlling hypertension within the population. The core aim
of the programme is reducing misdiagnosis by ensuring that all healthcare professionals in Canada are appropriately trained to diagnose hypertension and
follow recommended guidance to mange the condition. In addition there is a focus on building research and surveillance capacity and coordinating the
networking of local and national stakeholders.

Outcomes
Measure 2007-09 2010-11 2012-13
Hypertension Prevalence (2020 target 13%) 19.6% 21.8% 22.6%
Awareness of condition (2020 target 95%) 83.4% 82.9% 84.3%
Diagnosed with hypertension with normal BP while not 8.5% 11.1% 6.6%
on antihypertensive drug treatment a (i.e. lifestyle
control of hypertension) (2020 target 40%)
Appropriate drug therapy (2020 target 87%) 79.9% 79.2% 79.6%
Blood pressure under control (2020 target 78%) 65.9% 64.1% 68.1%

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Table 1J United States: Million Hearts

In 2012 the Million Hearts initiative was established by the US Department of Health and Human Services, the Centre for Disease Control and Prevention
(CDC) and Centres for Medicare and Medicaid (CMS). This national initiative had a first phase, 5-year goal, of preventing 1 million cardiovascular events by
2017, and is now in its second phase, Million Hearts 2022. The core aim of the work is to align CVD prevention efforts across 50 states and 120 partners in
the US by focussing on implementation of the ABCS approach to CVD management (Aspirin when appropriate, Blood pressure control, Cholesterol
management, and Smoking cessation). Meaningful use of health tools and technology such as electronic records for identifying and monitoring patient groups
and introducing policies to eliminate artificial trans-fat intake, reduce tobacco use and reduce sodium intake are other key elements of the initiative.

Outcomes

Measure 2005/06 2007/8 2009-10 2011-12 2013-14 2015-16

Aspirin use in people aged >40 (target NR NR 81.1% NR NR NR
70%)
Blood pressure control population level 43.4 48.4 53.4 51.9 54.0 57.7*
(target 65%)
Cholesterol control with statins – % statin 44.1 49.4 49.7 54.2 56.8* 59.9*
use among adults for whom it is
recommended (target 70%)
Smoking – prevalence (%) of current 28.2 26.9 26.2 25.1 24.0 23.0*
combustible tobacco use among adults
(target 23%)
Mean sodium intake among adults 3,697 3,595 3,594 3,618 3,534 3,525*
(mg/day) (target 2,900mg.day)
NR – not reported *Projected figures

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The case studies described in this report offer alternative models to CVD prevention than
those currently implemented in England. All the cases studies showed some evidence of
success in reducing CVD risk factors but some programmes were more applicable and likely
to be sustainable in a UK setting than others. None of the programmes stood out as having a
truly innovative approach. Indeed innovation was not an important factor in the success of
the programmes, but rather developing a tried and tested approach that successfully
engaged relevant stakeholders and that could be sustained in the long term and readily
transferred and tailored to other communities was more important.

Two programmes, Hypertension Canada and Million Hearts are national initiatives and foster
collaboration between health care providers and the implementation of evidence based
practice. Hypertension Canada focuses on research and the development of guidelines,
education of health care professionals to prioritise the accurate detection and management
of people with CVD risk. Million Hearts is a wide ranging national initiative with a small core
team who focus on promoting evidence based clinical quality improvement, detecting people
at risk of CVD using electronic health records, changing harmful behaviours such as
smoking, and high sodium and trans-fat intake. Organisations become partners in the Million
Hearts initiative and can secure funding though a variety of routes to support change in
practice. Both national programmes have not yet met their challenging targets but are slowly
progressing towards them using multiple approaches.

The case studies that developed a tried and tested sustainable approach that successfully
engaged relevant stakeholders that could be readily transferred to other communities whilst
reducing CVD risk, are arguably the most likely to be usefully adapted for use in England
and the wider UK. They were also the case studies that focused on long term sustainability
from the outset, and we suggest that this should be central to implementation of any
changes that follow from this work in the UK. The most successful three programmes
identified here from the evidence available (HONU, CHAP and COACH) all have a very
strong community focus although they are targeting different elements of prevention. They
are using schools, workplaces, community centres, pharmacies, or peoples own homes to
deliver the programme. HONU has the broadest approach drawing on all sectors of the
community, whilst CHAP has a more focused approach running community clinics to detect
CVD risk factors in the local population and COACH offers support in management of risk
factors by phone to people in their own homes. Going to where the people are, empowering
individuals and the wider community with information and an understanding of CVD risk, that
they can monitor themselves, is clearly important in the success of the programmes.

All three programmes built in mechanisms for ensuring that they were sustainable in the long
term with minimal continued investment which is a particularly important consideration, given
the constraints of resources at the current time. Strong leadership and governance of the
programmes was built into the mainstream running of each service or community
programme to ensure it was fully integrated as part of the approach to prevention. This led to
good community engagement and mobilisation with the use of volunteers to support the
delivery of the programmes in the case of HONU and CHAP. COACH meanwhile used and
trained a wider professional group to contact people at home to support them to be actively
engaged in reducing their own risk factors by optimising medication and making lifestyle
changes.

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Introduction
Cardiovascular disease (CVD) affects around seven million people in the United Kingdom
(UK) and is a significant cause of disability and death, affecting individuals, families and
communities. CVD is responsible for one in four premature deaths in the UK and was
responsible for 26% of all deaths (129,147) in England in 2015.3 Healthcare costs in the UK
associated with CVD are estimated to be about £8.96 billion and non-healthcare costs
estimated at about £4.04 billion at the time of the study by Wilkins et al (2017).4 There are a
number of different physiological and behavioural risk factors for CVD, including smoking,
high cholesterol, high blood pressure, poor diet, harmful drinking and physical inactivity. It is
also linked to a range of environmental and social factors, including air pollution and financial
inequalities.
Solutions for Public Health (SPH) was commissioned by the British Heart Foundation (BHF)
and Public Health England (PHE) to identify and describe cardiovascular disease prevention
programmes successfully implemented in countries outside the UK. SPH developed case
studies for 10 of these programmes that illustrate approaches that may be applicable and
effective within the UK. This report sets out how SPH undertook this project, the current
context in England and the case studies that emerged from the information gathering
process.

1 Aims and objectives

The purpose of this project is to:
 Identify, describe and critique a series of cardiovascular disease (CVD) prevention
programmes that are, or have been, implemented outside the UK
 Make recommendations for the implementation of effective CVD prevention
programmes in England and the UK
 Provide background and context of current CVD prevention programmes in England,
within which CVD prevention programmes from elsewhere may be implemented in
this country.

A broad range of prevention programmes are of interest, including initiatives focussed on

behavioural and medical risk factors and high risk conditions.

2 Methods
This project was built on the outcomes of PHE’s work to identify current and past CVD
prevention programmes implemented in the UK and internationally. PHE identified these
programmes through a structured review of published and unpublished literature and
developed a spreadsheet of relevant programmes and their outcome studies.
A steering group with representation from PHE, BHF and NHS England met monthly to
oversee the project and were consulted at key decision points over the lifetime of the project.
Identifying CVD prevention programmes to develop as case studies
PHE included 116 current and historic programmes in their spreadsheet and SPH undertook
a hand search which identified a further two CVD prevention programmes (a total of 118
programmes). Two initial inclusion/exclusion criteria were agreed with the steering group and

International CVD Prevention Case Study Report Page | 12

applied to the list of CVD prevention programmes to exclude those which were not of interest
as potential case studies. These criteria were:

 Programmes which were implemented and had final follow-up completed prior to
2007 were excluded
 Programmes where there was no publications published in the English language
were excluded.

The application of these inclusion/exclusion criteria resulted in a shortlist of 55

programmes from the 118 initially identified. The abstracts for these publications were
retrieved and used to appraise each of the programmes to aid decision-making about the
selection of case studies. The agreed factors for selection of the final programmes to be
used as case studies were:
1. The availability of published evidence about the intervention and the outcomes
2. Level of evidence e.g. size of study population and inclusion of a comparator
3. CVD risk factors targeted
4. CVD conditions targeted
5. Type of intervention (e.g. awareness raising, health check, case finding)
6. Whether the intervention targeted a broad or narrow population group
7. Local or national programmes.

From this exercise 8 programmes were selected and agreed by the CVD International
Review Steering Group which oversaw the project and comprised representatives from PHE,
BHF and NHS England. The strength and volume of evidence (factors 1 and 2) a mix of,
prevention focus (factors 3 and 4) and type of intervention (factor 5) were the most important
of the 7 factors in the selection process. Two additional case studies of national programmes
(Million Hearts and Hypertension Canada) were purposefully selected to be reviewed along
with those that met the original criteria. This is due to the particular interest of PHE and BHF
in the approach of community mobilisation and self management models used in supporting
reduction of hypertension, early detection of atrial fibrillation and high cholesterol.
Framework for organising case study information
Detailed information was gathered for each case study to populate a framework to ensure a
systematic approach. The framework used was the dynamic health systems framework (Van
Olmen et al 2012)5 which combines a range of previously published health systems
frameworks including the WHO system building blocks. This framework incorporates the
wider system elements of population, context, values and principles in addition to core health
system components of leadership and governance, health workforce, health information
systems, access to medicine and equipment, finance and service delivery.

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 5
Figure 1: Dynamic health systems framework from Van Olmen et al (2012)

5
Source: Van Olmen et al (2012)

Where possible, information was extracted from unpublished and published documents
readily available on the internet or through the British Library services. In addition SPH
undertook interviews with key staff for the programmes where available. This helped to fill
any significant gaps and obtain additional contextual information. The table in Appendix 1
shows the different elements of the framework and the type of content required for each
case study.
Once the information had been gathered it was organised in a consistent case study format
with two pages summarising the key points about the implementation, benefits and
limitations of each initiative. This was followed by more in depth information extracted from
peer reviewed publications.

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3 Background and context of cardiovascular disease prevention
in England
Rates of cardiovascular disease in the UK have been declining year on year since the
1960s, (Scarborough et al 20116). This decline took place across large parts of the world
including Western Europe, the United States of America (US) and Australia. The US
reported a 20% drop in mortality from coronary heart disease between 1968 and 1978
(Jones and Greene 20137). At the time it was unclear why this decline had taken place but
subsequent modelling pointed to better understanding of the risk factors for CVD, as well as
early prevention programmes and improved treatment. Capewell et al (1999), using Scottish
data for 1975-1994, estimated that risk factor reductions through prevention contributed 51%
to the decline in mortality rate and improved coronary care by a further 40%8.
By the year 2000 the rate of decline in CVD mortality had started to slow in the US from a
decline annually of -3.1% between 1970 and 1979 to -2.7% from 1990 to 19979. Modelling
by Ford and Capewell et al (2007)10 of US data suggested that improvements in blood
pressure, cholesterol and smoking were being offset by adverse trends in obesity and
diabetes. A similar plateau in the decline was also reported in Europe and Australia. The
consensus was that despite the predicted health gains that could be achieved, there was
fatigue from prolonged campaigns aimed at risk factor reduction, and sustaining prevention
initiatives required consistent political will11. The CVD risk reduction message is no longer
novel and is ever harder to follow, given the rise of the current obesogenic culture.
Latterly there has been a global resurgence in a full range of CVD prevention programmes.
These include community based interventions supporting people to reduce CVD risk through
lifestyle changes, targeting of high risk individuals and offering one to one support to improve
health and wellbeing. This is alongside initiatives to promote effective medical management
of risk factors such as hypertension, diabetes and high cholesterol levels to reduce the
likelihood of progression to a CVD event such as stroke, or a life limiting chronic disabling
disease such as heart failure.
According to the data extracted from the Global Burden of Disease Study (Institute of Health
Metrics, Washington http://www.healthdata.org/gbd), despite the declines in rates of CVD
over the past 50 years, cardiovascular disease still accounted for 30.15% deaths (282.41 per
100,000 population 95% CI; 275.71-289.29) in the UK in 2016, similar to the rate of cancers
(29.22%) at a rate of 273.67(95% Confidence Interval [CI]; 268.21 - 279.52) per 100,000
population. The next most frequent causes of death were neurological conditions which
accounted for less than 12% of the total.
Figure 2 uses the Global Burden of Disease (GBD) study data collated by the Institute of
Health Metrics (IHM) based in Washington (http://www.healthdata.org/gbd). The project
captures premature death and disability data for more than 300 diseases and injuries in 195
countries, by age and sex, from 1990 to the present. Figure 2 shows the trend in Disability
Adjusted Life Years due to cardiovascular disease for the four UK countries and a small
range of other countries from around the world. Disability Adjusted Life Years (DALYs) is a
measure of overall disease burden, expressed as the number of years lost due to ill-health,
disability or early death.
Greece has had the shallowest decline in CVD burden since 1990, and is similar to the
United States. Out of the 13 countries in Figure 2, these two countries had the 7th and 8th

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highest DALYs per 100,000 population in 1990, but in 2016 had the 1st and 2nd highest level
of CVD burden. In 1990, Scotland had a much greater CVD burden than all of the other
countries, but this steeply declined to half this rate by 2016. France and Japan started with
the lowest CVD burden in 1990. Their rates have steadily declined and they are still the
countries with the lowest CVD burden in 2016. England had the 6th highest burden of CVD in
1990 and in 2016 was 8th out of this group of countries, improving at a greater rate with a
steeper decline than Greece and the US.
Figure 2: Cardiovascular disease burden change between 1990 and 2016 in selected
countries
8000.00

7000.00
DALYs per 100,000 population (age standardised)

Australia
England
6000.00
France
Greece
5000.00
Ireland
Japan
4000.00
Finland

3000.00 United States

Wales

2000.00 Northern Ireland

Scotland

1000.00 Netherlands
Canada

0.00

Source: Global Burden of Disease Study 2016 (GBD 2016) Results. Seattle, United States: Institute for Health
Metrics and Evaluation (IHME), 2016. (http://www.healthdata.org/gbd)

Newton et al (2015) analysed the 2013 data from the GBD study, comparing potential years
of life lost from all causes across the 15 EU countries, the four UK countries, the nine
English regions, plus Australia, Canada, Norway and the USA. SPH has extracted similar
data from the GBD study for cardiovascular disease for the same countries and regions plus
Japan. The data is based on the latest information supplied by each country up to 2016.
Figure 3 shows the latest data available (2016) of age standardised years of life lost (YLL)
per 100,000 population from CVD. Years of life lost (YLL) or years of potential life lost
(YPLL) or potential years of life lost (PYLL), is an estimate of the average years a person
would have lived if he or she had not died prematurely. It is, therefore, a measure of
premature mortality. Currently CVD in Japan accounts for the fewest years of life lost per
100,000 population (1347, 95% Uncertainty Interval [UI]; 1292 - 1400) and Greece the most
(2987, 95% UI; 2770 - 3204). Of the 10 areas with the highest rate of YLL due to CVD, six

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are from the UK and include the English regions of Yorkshire and the Humber, Northern
Ireland, North East and North West England, Wales and Scotland.
Figure 3: Global Burden of Disease Study - age standardised rates of years of life lost
(YLL) from CVD per 100,000 population in 2016 for the nine English regions, 4 UK
countries, 15 EU countries and Australia, Canada, Norway, the USA, and Japan for
both sexes.
Japan
France
Switzerland
Spain
Australia
Netherlands
Norway
South East England
Denmark
Canada
Italy
South West England
East of England
Belgium
Greater London
England
Portugal
Sweden
East Midlands
United Kingdom
West Midlands
Ireland
Austria
Yorkshire and the Humber
Northern Ireland
North East England
North West England
Finland
Wales
Germany
Scotland
United States
Greece
0 500 1000 1500 2000 2500 3000 3500
Source: Global Burden of Disease Study 2016 (GBD 2016) Results. Seattle, United States: Institute for Health
Metrics and Evaluation (IHME), 2016.

In the UK, the South East region has the lowest YLL per 100,000 population from CVD at
1724 (95% UI; 1659 - 1793) whilst Scotland has the highest YLL per 100,000 population
from CVD at 2522 (95% UI; 2320 - 2860).
Figure 4 shows the years of life lost to disability (YLD) from CVD by each country and
English region. This measure is determined by the number of years disabled, weighted by
level of disability caused by a disability or disease.

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Figure 4: Global Burden of Disease Study - age standardised rates of years of life lost
to disability (YLD) per 100,000 population due to CVD in 2016 for the nine English
regions, 4 UK countries, 15 EU countries, and Australia, Canada, Norway, the USA,
and Japan for both sexes.

Australia
Spain
Japan
Italy
Switzerland
Canada
Portugal
Netherlands
Ireland
United States
Greater London
Denmark
West Midlands
Greece
Yorkshire and the Humber
North East England
France
England
United Kingdom
South West England
South East England
East Midlands
Northern Ireland
Wales
North West England
Scotland
Norway
East of England
Germany
Finland
Austria
Belgium
Sweden
0 100 200 300 400 500 600 700 800

Source: Global Burden of Disease Study 2016 (GBD 2016) Results. Seattle, United States: Institute for Health
Metrics and Evaluation (IHME), 2016.

Within the UK, the YLD from CVD in 2016 were lowest in Greater London at 464 per
100,000 population (95% UI; 338 - 610) and highest in the East of England at 494 per
100,000 population (95% UI; 361 - 649). Of the countries included in Figure 4, years of life
lost to disability from CVD were lowest in 2016 in Australia at 359 (95% Ul; 261 - 499) per
100,000 population compared to Sweden at 534 (95% UI; 390 - 699) per 100,000 (Figure 4).
It should be noted that the Global Burden of Disease study data is constantly being updated
and countries will frequently move up and down the rankings from year to year. It is
important to link back these snapshots in time to the overall trends shown in Figure 2. This
shows that in order to achieve rates nearer to those of Japan, France and Australia

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acceleration in CVD prevention is needed to shift the England trend line to a steeper
downward trajectory away from its current plateau.

4 Strategies for CVD prevention in England

In September 2017 PHE published their action plan for cardiovascular disease prevention for
2017 and 201812, and the NHS Prevention board have prioritised this topic and proposed
actions in their update to the NHS five year forward view (Next steps on the five year forward
view, 201713). These plans go beyond the activities undertaken by NHS England and PHE
and incorporate actions by government, local authorities, employers and third sector
organisations alone and in partnership. Not only do CVD prevention initiatives cut across
organisational boundaries, but they cannot be considered in isolation from other non-
communicable diseases which are impacted by the same risk factors. The multiple risk
factors for CVD are also risk factors for other non-communicable diseases such as cancer,
COPD, diabetes, and dementia. Figure 5 shows the different risk factors and their attribution
to the disease burden of non-communicable diseases in England in 2013.
Figure 5: Percentage of disease burden in England (2013) that is attributable to each
risk factor, by disease group (Disability Adjusted Life Years)

1
Source: Public Health England (2016)

The overall national approach to CVD prevention is to focus on the risk factors in Figure 5
with initiatives that make it easier for healthy people to remain healthy and for those at high
risk or already diagnosed with CVD to change their behaviour and receive optimal medical
management to meet risk factor targets. The particular combination of population-wide
strategies and strategies targeted at high risk individuals depends on achievable
effectiveness, as well as cost-effectiveness and availability of resources. This results in a

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plethora of different types of initiatives across the country that range from making the built
environment a place to encourage physical activity to ensuring patients are on the
recommended dose of statins so their target lipid levels are more likely to be achieved.
There are a range of community and primary care settings where prevention, detection and
management of CVD can occur including pharmacies, the NHS Health Check programme,
routine GP and nurse appointments and local health promotion initiatives. Detection of a
high risk of CVD can also be determined automatically by interrogating GP medical records
to identify people with a combination of recent medical test results that indicate high risk of
CVD. In these cases people might be invited directly to participate in a risk reduction
programme such as the NHS Diabetes Prevention Programme without having first been in
contact with a health professional.
Figure 6 and Figure 7 below illustrate the Right Care CVD risk prevention pathway and the
difference that effective CVD prevention across all risk factors could make.
As primary care is currently under significant pressure, CVD prevention will benefit from a
focus on increasing capacity and capability, using established resources innovatively and
identifying potential new routes for detection and management of those with increased risk of
CVD. There is considerable scope to improve prevention of CVD within primary care and
community settings as outlined in Figures 6 and 7. In 2017 PHE and NHS England
quantified some of the benefits that would accrue from optimal detection and treatment of
CVD risk factors (The Size of the Prize, 201714).There are an estimated 13.5 million adults
with hypertension in England of which 5.5 million are undiagnosed and a further 1.5 million
with known hypertension are not reaching the Quality Outcomes Framework (QOF) target
blood pressure of 150/90Hgmm. If only half of all people diagnosed with hypertension were
optimally treated over a three year period this would result in 4,855 fewer heart attacks
(saving £36 million) and 7,250 strokes (saving £100 million). There are just under a million
people with diagnosed Atrial Fibrillation (AF) in England on GP registers and a further
400,000 people estimated to be undiagnosed. Around 170,000 people are estimated to have
AF at high risk of causing a stroke but who are not receiving optimum anticoagulation
treatment. If only half those people who are at high risk of AF were optimally treated over
three years there would be an estimated 7,110 fewer strokes (saving around £125 million).

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Figure 6: Summary of Risk Factors and How These are Detected and Managed in Primary Care

International CVD Prevention Case Study Report Page | 21

Figure 7: Summary of Cardiovascular Disease Prevention Individual and Population Interventions

International CVD Prevention Case Study Report Page | 22

The socio ecological model as a focus for prevention programmes
The Social Ecological Model has been used in multiple areas of public health to improve our
understanding of the interplay between different elements of society and how these will
impact on health promotion initiatives. By using this model to organise examples of the
different types of initiatives that will impact on CVD currently undertaken in England
(Appendix 2) it is possible to better understand their context and approach. It is also a helpful
way to frame each of the case studies set out in Section 5.
Originally developed to model human development in the 1920s15 the ecological model has
been modified to apply to a range of different societal systems including politics, economics,
communications and public health. Drawing from natural ecosystems, defined as the
network of interactions among organisms and between organisms and their environment,
social ecology is a framework or set of theoretical principles for understanding the dynamic
interrelations among various personal and environmental factors. Applied to health
promotion the Social Ecological Model (SEM) is a framework for understanding the
multifaceted and interactive effects of personal and environmental factors that determine
behaviors.16
Figure 8: Social Ecological Model

5.National policy, legislations,

guidance

4.Wider community
organisations working together

3.Local organisation, local health

service, schools, work places

2.Family, friends, peers,

work colleagues

1.Individual
age, gender,
knowledge, skills,health
status attitudes,
behaviours

Source: Adapted from the Centers for Disease Control and Prevention (CDC), The Social Ecological Model: A
Framework for Prevention, http://www.cdc.gov/violenceprevention/overview/social-ecologicalmodel.html

There are five nested levels of the SEM which illustrate the interplay between individual,
interpersonal, local organisations, community and national influences. An approach that

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incorporates combinations of interventions at several levels is more likely to achieve and
sustain success over time than a single intervention.
Changing individual level behaviors and creating new social norms is achieved through
removing bottlenecks and barriers to the new behaviors.
In terms of cardiovascular disease prevention Figure 9 below illustrates the multitude of
factors at each level that are important in influencing lifestyle behavior, detection and
management of CVD. Examples of policy, strategy or guidance in England that aim to
address those factors at each of these levels are given in Appendix 2. This list is not
exhaustive but gives a feel for the current principle activities taking place.
Figure 9 Examples of key influences on CVD risk factor reduction at each level of the
socio ecological model.
•Food industry approach reformulation of foodstuffs
•Political will to legislate
5.National •Evidence based CVD policy
•Public health marketing strategy
•Construction industry approach to developing healthy towns

•Food outlets offering healthy options

•Availability of safe green spaces
•Built environment conducive to walking, cycling and playing
4.Community •Active travel options
•Community challenges
•Local authority public health strategy
•Local health services capability and capacity
•Employers implementing healthy workforce activities
•Schools implementing initiatives to promote physical activity
3.Local organisations and healthy diet.
•Local food outlets offering healthier options
•Leisure centres and other fitness businesses offering a range
of fitness classes

•Understanding of/and views of health and wellbeing in

2.Family, friends, peers, relation to lifestyle factors by friends and family
•Family traditions and customs
work colleagues •Work place colleagues views about taking up work place
challenges
•Understanding CVD risk factors
•Accessible format of information
•Information about how to know your own CVD risk
•Access to resources and support to change behaviour
1.Individual •Individual preferences
•Individual attribues eg: gender, ethnicity, age, language
•Physical and mental capability to apply knowledge

The Social Ecological Model is a helpful way to understand the approach of each of the
international programmes that were chosen to develop into a case study.

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5 Case studies
Following the application of the methodology described in section 2.1, 10 CVD prevention
programmes from across the world were chosen to be developed into case studies. The
programmes were a mix of prevention approaches, some were single interventions and
others were programmes with multiple initiatives. They were all multifaceted in that they
targeted a range of modifiable CVD risk factors including those that would benefit from
lifestyle change and/or optimisation of medical management. Some programmes also
described in detail how people with undetected high risk of CVD were identified.

Five of the case studies focus on people with high risk conditions. Those with current CVD or
a high risk of CVD are offered interventions to reduce their risk with the aim of averting
further morbidity and impact on health services. The remaining five case studies are
programmes with a combination of prevention approaches encompassing both prevention of
CVD and reducing CVD risk factors. These programmes typically comprise multiple small
initiatives under one programme umbrella.

Australia: Coaching patients On Achieving Cardiovascular Health (COACH)

The COACH Program® (Coaching patients On Achieving Cardiovascular Health) was
developed in 1995 in Melbourne and is currently available in all Australian states. It focuses
on increasing the engagement of individuals in understanding and improving their own
health by increasing capacity and capability in local health services (Socio Ecological Model
levels 1 and 3).

The programme looks for ways to reduce future cardiovascular disease (CVD) risk in those
people already diagnosed with CVD or at high risk of an event. The focus is on lifestyle
change and identifying ‘treatment gaps’ where medication has not been optimised. Health
professionals, trained in the COACH system, mentor the patient on changes in lifestyle and
support them in working with their usual doctor to ensure treatment is optimised for their
particular circumstances, based on national guidance in order to reach target levels for their
modifiable risk factors.

COACH is a structured telephone and mail-out health programme for people with chronic
disease.
There are five stages to each phone coaching session:
 Finding out what the patient knows: ask patients questions to find out what they
know about their risk factors and treatment for their risk factors
 Education: tell patients what they should know
 Patient empowerment: empower patients to ask their own doctor(s) to measure
their risk factors; provide them with their test results; prescribe appropriate
medication and alter doses/ drugs if appropriate
 Action plan: set an action plan to be achieved by the next coaching session
 Monitoring: check what action has taken place since the previous coaching session
and use the information as the basis for the next session.

The COACH Program runs for approximately six months with telephone-based coaching
sessions every four to six weeks. At the end of each session a letter detailing the topics
discussed is sent to the patient and the doctor(s). Patients receive a written information pack

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at the start of the programme. Coaches are all health professionals including nurses,
dieticians, pharmacists, physiotherapists and occupational therapists. Patients need four or
five coaching sessions to make progress and a full time coach can take on somewhere
between 200 to 250 patients a year. COACH has been operating with BUPA in the UK for
five years and has been adapted for UK guidelines.

A multicentre randomised controlled trial (n=792)17 has demonstrated greater improvements

at six-months follow-up for patients receiving COACH in addition to usual care compared to
usual care alone:
 COACH patients had significantly better total cholesterol, LDL cholesterol, BMI,
saturated fat intake, proportion of patients taking lipid-lowering drugs, a higher
proportion of people taking up walking since discharge and lower anxiety levels
 There was no significant difference at six months in HDL cholesterol, triglyceride
levels, blood pressure, fasting glucose, smoking or depression score.

Longer-term follow-up of RCT18 participants has shown that improvements in risk factor
status and adherence to medications following COACH are sustained for 18 months. For
example:
 The percentage of patients achieving the total cholesterol target was 27% before
COACH, 57% immediately after COACH and 52% 18 months later
 The percentage of patients undertaking physical activity was 70% before COACH,
94% immediately after COACH and 92% 18 months later.

A four-year follow up of RCT participants has shown that four coaching sessions over six
months is associated with significant reduction in:
 Any-cause hospital admissions (by 16%)
 Any-cause hospital bed days (by 20%)
 Cardiac bed days (by 15%).

When assessing the published literature for the case studies COACH had more evidence
based publications outlining the benefits to patients and the health economy than any of the
other programmes. Detail of the evidence from some of these publications is outlined in the
COACH case study (Appendix 3).

Finland: DEHKO and One Life

DEHKO, was launched in Finland as part of the Finnish National Diabetes Programme,
established as a ten year programme running from 2000 to 2010 and aimed to improve self-
care, prevent and reduce complications from type 2 diabetes. From 2011, the DEHKO
programme expanded to include raising awareness and reducing risk of non-communicable
diseases with common risk factors including cardiovascular disease (CVD), dementia,
chronic obstructive pulmonary disease (COPD) and type 2 diabetes. This programme ‘One
Life’ is supported by a collaboration of the Finnish Diabetes, Brain and Heart Associations
and focuses on supporting people to make lifestyle changes to improve modifiable risk
factors.

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The principle elements of DEHKO are:
 Prevention of type 2 diabetes through:
o A whole population strategy
o A high risk population strategy
o A strategy of early detection and management
 Improving quality of care of people with type 2 diabetes with a focus on reducing the
risk of cardiovascular disease
 Supporting self-care of people with type 2 diabetes.

In addition One Life focusses on:

 Raising awareness of cardio-vascular health amongst the general population
 Improving the health outcomes of patients with cardiovascular disease through
education and improved access to care.
One element of DEHKO was the FIN D2D project conducted in 2003–2008 supporting the
implementation of the prevention of T2D in five hospital districts (about 400 health care
centres/occupational health care clinics) in Finland with existing resources. This project was
evaluated and showed:
 In the FIN-D2D area 25% of men and 48% of women were aware of the programme
compared to a control area, where the proportions were 20% and 36% respectively
 Over a 12 month period of the high risk population intervention, those men and
women who reported changing their physical activity and diet had a decrease in
estimated 10-year risk for CVD events by 3.5% in men and 1.5% in women
compared to an increase of 0.15% in men (p<0.001, between groups) and decrease
of 0.43% (p=0.027, between groups) in women who did not make the changes
 There was no change in estimated mortality in individuals at high-risk of T2D.

Of people who attended the health check-ups and individual/group sessions, men reported:
 An increase in physical activity and improved dietary pattern (9.6%)
 An increase in physical activity (4.1%)
 An increase in improved dietary pattern (39.3%)
 No lifestyle changes (47.0%).
Women reported:
 An increase in physical activity and improved dietary pattern (14.2%)
 An increase in physical activity (3.8%)
 An increase in improved dietary pattern (39.2%)
 No lifestyle changes (42.7%).

The high risk population strategy in the FIN D2D study may be useful and applicable to
primary health care settings’ strategies relating to T2D and CVD. However, commitment to
lifestyle changes in primary health care was rather low, which is why increased motivation
and self-management of people at risk should be emphasised.
Detail of the evidence from some of these publications is outlined in the DEHKO case study
(Appendix 4).

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France: ESCAPE
ESCAPE, conducted in France from 2006-2008, was a pragmatic cluster randomised
controlled CVD prevention trial19. It was designed to show whether a multifaceted
intervention, aimed at general practitioners (GPs), could significantly increase the proportion
of hypertensive patients at high risk of cardiovascular disease (CVD) who achieved all their
recommended therapeutic targets. In terms of the socio ecological model this programme
focussed on developing the local health capability and capacity to optimise management of
people with a high risk of CVD (SEM level 3).

GPs in the intervention group received one day of medical education on therapeutic targets
and strategies featured in the French guidelines on treatment of hypertension and type 2
diabetes, and were given a validated electronic blood pressure measurement device to
improve the accuracy of blood pressure measurements and a leaflet that summarised
targets and therapeutic strategies. GP participants were all members of the French National
College of Teachers in General Practice.

To be included, patients had to be aged between 45 and 75 years, be treated for

hypertension for at least six months, not have any known clinical signs or history of CVD,
and have at least two cardiovascular risk factors from a list of eight including age, family
history, smoking, type 2 diabetes, LDL or HDL cholesterol levels, known left ventricular
hypertrophy and urinary excretion of albumin.

Key primary outcomes from the trial are:

 After two years, the proportion of patients achieving all their therapeutic targets
increased significantly in both groups, but significantly more in the intervention group
with between group OR (odds-ratio) of 1.89, (95% CI); 1.09 - 3.27, p = 0.02)
 Significantly more patients achieved their blood pressure targets in the intervention
group than in the usual care group: OR 2.03 (95% CI; 1.44 - 2.88, p < 0.0001)
 Systolic and diastolic blood pressures decreased significantly more in the
intervention group than in the usual care group, by 4.8 mmHg and 1.9 mmHg,
respectively (p < 0.0001 for both SBP and DBP).

The authors suggest that the absolute difference in the reduction of SBP of about 5mmHg in
the intervention group was clinically relevant because this difference could be expected to
reduce stroke mortality by 20%, and mortality related to cardiac ischaemic events or long-
term overall cardiovascular mortality by 15%.

For more detail about the evidence published from this trial see the France ESCAPE case
study in Appendix 5.

The Netherlands: Vascular risk management

This programme assessed the effectiveness of adding internet-based, nurse-led vascular
risk factor management to usual care for patients with clinically manifest vascular disease. In
terms of the socio ecological model this programme focussed on development of the local
health capability and capacity to engage people in reducing their CVD risk by changes in
lifestyle and optimal management of their condition (SEM levels 1and 3). This programme
was part of a research trial with eligible patients, recruited20 between 2008-2010, who had a

International CVD Prevention Case Study Report Page | 28

recent clinical manifestation of a vascular disease and a number of risk factors that were not
at the recommended levels.
Key elements of delivery for patients in the intervention group included:
 A personalised website detailing the patient’s risk factors that required additional
treatment
 A separate internet page for each risk factor with a history of risk factor
measurements, drug use, treatment goal, advice from the nurse, correspondence
between nurse and patient and news items for that particular risk factor
 Patients were asked to log in fortnightly to submit new measurements (blood
pressure, weight, smoking status, cholesterol) and to read and send messages
 Patients were encouraged to measure their own blood pressure at home or ask their
GP to measure their blood pressure. The nurse posted patients laboratory forms for
blood tests to measure plasma lipids and glucose
 Prescriptions for changes in drug regimen were posted to patients.

The key outcome of the programme after 12 months was that:

 When adjusted for differences in the baseline score, the relative change in
Framingham risk score of the intervention group compared to the usual care group
was not statistically significant at -8% (95% CI; -18% to - 2%)
 The difference between groups in patients reaching the low density lipoprotein goal
was 18.4% (95% CI; 5.9% - 30.9%, p=0.004)
 The difference between groups in change in patients who quit smoking at 12 months
was 7.7% (95% CI; 0.4 - 14.9, p=0.038).

The cost effectiveness analysis measured societal costs, quality-adjusted life-years (QALYs)
and incremental cost effectiveness21. It concluded that the intervention in addition to usual
care does not result in QALY gain at one year, but has a small effect on vascular risk factors
and is associated with lower costs.
Treating patients at the point where they are likely to be concerned about mortality and may
be self-motivated to take action was considered to be effective and lower cost. It was seen
as productive for patient and nurse to work together collaboratively to reduce risk factors and
for patients to take responsibility for their health and be part of the solution. It is also an
opportunity to involve carers in cardiovascular risk management, rather than just surgery or
medication straight after the event.

The ability of patients to see their results online as soon as they were available was a
controversial step. One view was that patients may access results without health
professional support which could be distressing. In some areas there is a delay of a day or a
week between request to access results by the patient and the result being available to view
by them to give health professionals time to check their significance.

After the programme was finished (1 year) the functionality of the website for patients to
retrieve their own records was incorporated in to the local health electronic record system.
During the trial people could enter their own numbers, lab results from the GP, or blood
pressure taken at home, but they cannot do that in the current system.

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Other features of the programme including an extended outpatient appointment to review
risk factors and ongoing communication to review progress in changes to modifiable risk
factors have been incorporated into the usual care of patients. Nurses can set up this system
of enhanced support if they think it might be effective for patients coming through the CVD
outpatients department after an event.

For more detail about the evidence published about this programme see the case study in
Appendix 6.

Canada: The Cardiovascular Health Awareness Program (CHAP)

The Cardiovascular Health Awareness Program (CHAP) was developed in Ontario, Canada.
CHAP aims to improve the process of care related to the cardiovascular health of older
adults.
CHAP started as a research study piloting a community based model of cardiovascular
disease (CVD) prevention in two communities. CHAP encourages older people to become
more aware of their cardiovascular risk and to acquire self-management skills. The
programme covers the individual, local organisation and community levels of the socio
ecological model (SEM levels 1, 3, 4).
Key elements of CHAP are:
 Free cardiovascular risk assessment and education sessions held in community
pharmacies
 Family physicians invite their patients over 65 to attend and sessions are also
advertised in the local community
 Sessions run by volunteer peer health educators
 Community Health Nurses train the volunteers, provide quality control and are on call
to assess people with elevated blood pressure
 During the sessions volunteers assist patients to take and record their blood pressure
using an automated device and complete a CVD risk profile (based on blood
pressure, previous hypertension diagnosis and lifestyle risk factors)
 Patients are told about the importance of reducing lifestyle CVD risk factors and sign
posted to community agencies and resources for support
 Family physicians receive feedback on patients attending sessions.

Key outcomes:

 A longitudinal study of 13,596 people who attended ≥2 CHAP sessions in 22

communities reported average blood pressure for patients with initially high blood
pressure improved from 142/78mmHg to 123/69mmHg over the 18-months follow-
up22
 Exposure to CHAP was associated with a 9% relative reduction in a composite
measure of hospital admissions for acute myocardial infarction, stroke and
congestive heart failure. This was equated to 3.02 fewer annual hospital admissions
per 1,000 people aged ≥6523
 There were statistically significant reductions favouring the intervention for acute
myocardial infarction (rate ratio 0.87, 95% CI; 0.79 - 0.97, p=0.008) and congestive
heart failure (rate ratio 0.90, 95% CI; 0.81 - 0.99, p=0.029)23

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  There was no significant difference for stroke (rate ratio 0.99 95%CI 0.88 to 1.12,
p=0.89)23
 When calculated as number of unique people admitted to hospital there was a
significant difference favouring CHAP in newly prescribed antihypertensive drug
treatment (rate ratio 1.10, 95% CI; 1.02 - 1.20, p=0.02)23
 There was no significant difference in all-cause mortality (rate ratio 0.98, 95% CI;
0.92 - 1.03, p=0.38) or in-hospital death from CVD (rate ratio 0.86, 95% CI; 0.73 -
101, p=0.06)23
 There was no significant difference in all-cause mortality or in-hospital death from
CVD23.
CHAP is a community-driven and community-owned initiative. It is designed to be a scalable
service that minimises centralised support over time to achieve a long-term sustainable
service. Since it began, the CHAP model has also been applied in a range of different types
of communities where it is tailored to maximise participation from the target group. For
example:
 South Asian community in Ontario, Canada
 Rural community in Alberta, Canada
 Social housing developments in Ontario, Canada
 Rural community in the Philippines.

For more detail about the CHAP programme see the case study in Appendix 7.

Japan: Healthy Japan 21

As part of the Healthy Japan 21 strategy, Japan has embarked on a national health policy
change to prevent lifestyle-related diseases, including cardiovascular disease (CVD) and
diabetes. National legislation requires employers and local governments to offer annual
‘health check-ups’ focussed on CVD, cancer and life style risk factors. There are financial
incentives for employers, so uptake is typically high. The full Healthy Japan 21 strategy has
developed initiatives at all five levels of the socio ecological model. One initiative outlined in
this case study focusses on an intervention for those at high risk of developing either CVD or
metabolic syndrome.

The basic health check-up includes: a blood pressure test, waist circumference, height and
weight, blood tests (lipids, triglycerides, HDL and LDL cholesterol, blood sugar (HbA1c,
fasting blood sugar), hepatic function, red blood cell count, haemoglobin level, and
haematocrit), electrocardiogram and urine tests for chronic kidney disease. A questionnaire
about lifestyle is focused on diet, tobacco smoking, physical activity, work life balance and
family history of disease. Results of tests are graded A to D and sent to individuals and their
employer (if the test was provided by the employer). For those at risk of CVD or metabolic
syndrome the following intervention is offered which comprises:

 Sessions of 20 minutes or more for each individual or 80 minutes or more to a group,

by a physician, public health nurse or registered dietician
 In the sessions a facilitator provides motivational support, explains the necessity of
lifestyle improvement, the relationship between lifestyle and the health check-up
data and the person’s lifestyle

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  An explanation is given about the advantages of lifestyle improvement and the
disadvantages of failing to improve lifestyle
 The facilitator suggests changes needed to improve the lifestyle (e.g. diet and
exercise) and sets goals for actions and signposts people to community resources
for support
 The facilitator shows how to measure body weight and abdominal circumference
 A follow-up interview is performed if the facilitator and participant feel it would be
helpful
 An evaluation of progress via interview, telephone or other method is carried out six
months after the first session.

Evaluation24 of this intervention reported:

 Clinically relevant reductions, i.e. >5% at year 3, were achieved in a significantly

higher percentage of participants of the lifestyle intervention compared to non-
participants (Waist circumference (WC), 21.4% vs 16.1% and BMI, 17.6% vs 13.6%;
p<0.001, each)
 Participants who received lifestyle intervention had significantly more improvements
in metabolic syndrome, as compared with non-participants who did not receive a
lifestyle intervention (reversal of metabolic syndrome: 47.0% vs. 41.5%, p<0.001)
 After adjusting for confounders, lifestyle intervention was associated with an adjusted
odds ratio (OR) of 1.33 (95% CI; 1.31 - 1.36, p<0.001) for 5% reduction in WC; 1.36
(95% CI; 1.33 - 1.38, p<0.001) for 5% reduction in BMI; and 1.31 (95% CI; 1.29 -
1.33, p<0.001) for reversal of metabolic syndrome)
 The mean WC changes were −1.34 and −0.44 cm in participants and non-
participants, respectively, with a difference of −0.89 cm (95% CI; −0.92 to −0.86)
 The mean BMI changes were −0.29 and −0.08 kg/m2 in participants and non-
participants, respectively, with a difference of −0.22 kg/m2 (95% CI; −0.22 to −0.21)
 Participants, compared to non-participants, had significant reductions in systolic
blood pressure (SBP, −1.15 vs −0.72 mm Hg), diastolic blood pressure (DBP, −0.97
vs −0.64 mm Hg).

The use of annual health check-ups for the whole population means that individuals,
employers and health professionals can track the progress in reducing CVD risk factors and
where improvements can be made.

For more detail about the evidence published about this programme see the case study in
Appendix 8.

United States: Franklin County

Franklin County is a low income rural community in Maine, USA. An integrated, community-
wide comprehensive cardiovascular risk reduction programme was started in 1970 with a 40-
year follow-up assessing the impact of risk factor improvements on reductions in morbidity
and mortality.
The programme aimed to focus public, individual and health professional attention on the
importance of long-term risk factor detection and control with initiatives at levels 1 to 4 of the
socio ecological model. Key features of the programme through the decades include:

International CVD Prevention Case Study Report Page | 32

  In the 1970’s the programme emphasised the detection and control of hypertension.
Volunteer nurses and trained community volunteers ran screening, education and
follow-up clinics in community centres
 Volunteer citizen and professional task forces initiated, promoted and staffed diverse
projects promoting healthy eating
 The programme promoted various initiatives to increase physical activity and improve
access to facilities
 In the 1980’s the programme emphasised the detection and control of
hyperlipidaemia using the same community-outreach model used for hypertension
 Between 1988 and 2011 a number of initiatives promoted smoking cessation. These
were run by teachers, volunteer health professionals and high school students
 From 2000 nurses were located in medical practices to facilitate the care of complex
patients
 The programme developed relationships with local media, with regular programme
updates and features on health topics.

Health promotion projects later combined into a hospital-supported Healthy Community

Coalition which served as the policy, co-ordinating and goal-setting body for the area’s
health education, promotion and prevention activities. Volunteer citizens and professionals
formed regional task forces.
The main outcomes from the programme include:
 In Franklin County (part of the US state of Maine) mortality rates (age and income
adjusted) decreased below Maine rates during 1970 to 2010, with the greatest
differences coinciding with the peak programme activities25
 From 1994-2006 Franklin County’s observed hospitalisation rate was significantly
lower than predicted by household income (observed vs expected difference -17
discharges per 1,000 population)25
 The lower than expected hospitalisation rates were associated with $5,450,362
(£3,919,300) reductions in total in and out of area hospital charges for Franklin
County residents per year25
 The proportion of people with treated and controlled hypertension improved from
1974/75 to 1977/8 (an absolute increase of 24.7%)25
 The proportion of people with treated and controlled cholesterol levels improved from
1986 to 2009 (an absolute increase of 28.5%). People with more programme visits
had better control25
 Smoking quit rates (ever smokers who report they have quit) improved from 48.5% in
1994-5 to 69.5% in 2006-10, with Franklin County quit rates significantly higher than
those seen in Maine and the US.25

The programme responded to changing demographics and financial support by taking the
service to the people. For example, senior citizens initially had access to free grant-
supported buses to attend community blood pressure clinics. When this transport became
less available, the programme took the service to seniors’ group meetings. When attendance
at these meetings diminished, the programme used a donor-sponsored mobile van that took
services to a wide variety of locations including shopping centres. This mobile service
offered risk factor assessment, referral and coaching.

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For more detail about the evidence published about this programme see the case study in
Appendix 9.

United States: New Ulm Heart Beats Back

New Ulm is a small community of 17,000 people. Local health organisations were keen to
track the cardiovascular health of the population before and during the implementation of
community wide interventions. The Health of New Ulm (HONU) project implemented
individual, family and organisational and community level interventions (levels 1 to 4 of the
socio ecological model) in order to influence behaviour and reduce modifiable cardiovascular
disease (CVD) risk factors.
HONU gathered cardiovascular risk data either from electronic records or from community
based CVD risk assessments held three times a year in New Ulm
 People at risk of CVD or with pre-diabetes were assigned a health coach to support
lifestyle change
 Families were invited to come together once a month and do physical activity and
cook together and take part in taste testing
 HONU worked with employers to support them to offer health and wellness activities
in the workplace
 A systematic method was used to assess how nutritionally healthy all food outlets
were and supported a shift to more healthy options including smaller portion sizes
 HONU implemented community health challenges around diet and activity
 The project worked with local government on integrating a health approach when
planning changes to the built environment
 Safe walking and cycling routes to school and other school based activities were
promoted to parents and children.

Part way through the 10 year programme funding period, plans for ongoing sustainability
were put in place to ensure continuation of the multifaceted approach.
Outcomes of a study assessing population-level CVD risk factors over a six year time frame
before and during project implementation are outlined in Table 1.

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Table 1: Change in CVD risk factors with the HONU project (Sidebottom et al 2016)26
2008-9 2010-11 2012-13
Blood pressure at goal* 79.3% 82.3% 86.4%
On blood pressure medication* 41.8% 43.5% 44.0%
Low-density lipoprotein at goal* 68.9% 72.3% 71.1%
High-density lipoprotein at goal 63.8% 59.0% 58.0%
Cholesterol at goal* 59.2% 64.2% 64.1%
Triglycerides at goal* 66.3% 68.7% 70.2%
On lipid medication* 25.3% 27.7% 29.1%
Not obese 56.0% 55.5% 55.1%
Fasting glucose at goalǂ 46.9% 49.7% 48.2%
On aspirin medication* 29.3% 33.5% 36.0%
Smoking 11.3% 12.6% 13.6%
Mean (±SD) ASCVD 10-year risk score* 12.1±0.2 11.6±0.2 11.5±0.2
ASCVD 10-year risk score <7.5% 27.8% 28.9% 27.5%
*Change between 2008/9 and 2012/13 p<0.001
ǂ
Change between 2008/9 and 2012/13 p=0.023
ASCVD – atherosclerotic cardiovascular disease 10 year risk score

The study by Sidebottom et al (2016)26 shows improvements (p<0.001) in meeting blood

pressure cholesterol and triglycerides recommended levels. There were also improvements
in the proportion of people on recommended levels of blood pressure and lipid medications
and mean reduction in CVD risk score. Other outcomes include an increase in CVD risk
awareness and increased participation of members of the community in a range of initiatives
focused on increasing physical activity, improving diet and reducing tobacco smoking.
The programme began with funded researchers dedicated to working with particular sectors
of the community such as schools, health services, employers and food outlets. This funding
was available for 10 years and the community is now in the process of taking on the full
scope of the prevention programme. This is a long term approach which needs to be
sustained and supported by all sectors of the community in order for a reduction in CVD risk
factors to continue.
The New Ulm community is relatively small and it is not clear whether if implemented in a
larger more varied population similar reductions in CVD risk would be achieved. This may
however be an approach useful to more rural towns.
For more detail about the evidence published about this programme see the case study in
Appendix 10.

Canada: Hypertension Canada

Hypertension Canada was formed in 2010 from the merger of the Canadian Hypertension
Society, the Canadian Hypertension Education Program and Blood Pressure Canada.
Previously, all three organisations had worked independently to improve hypertension
diagnosis and management and had been involved in the development of the national
hypertension strategy (Pan Canadian Hypertension Framework, 2011).
The main goal for Hypertension Canada is to ensure that Canada is effective in controlling
hypertension within the population. The core objective of the initiative is reducing
misdiagnosis by ensuring that all healthcare professionals in Canada are appropriately
trained to diagnose hypertension and follow recommended guidance to mange the condition.

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In order to achieve this there are three main areas of activity that fall into levels 3, 4 and 5 of
the socio ecological model:
 Research - Building capacity and undertaking hypertension surveillance by
monitoring the progress of hypertension treatment and prevention initiatives in
Canada and establishing a Chair in the Canadian Institute of Health Research
(CIHR).
 Education - Improvement of diagnosis and management through dissemination of
annual evidence based guidelines and the establishment of a national public and
professional education programme.
 Advocacy - Collaboration with stakeholders and governments to create supportive
environments through improved awareness, prevention, and treatment that
encourages the development of community interventions and programmes.

The October 2015 update to the 2011 Pan Canadian Hypertension Strategy detailed the
progress made so far in achieving the various 2020 targets (Table 2). Effective management
of those already diagnosed with hypertension has been more successful than the uptake of
lifestyle interventions.
Table 2: Progress towards 2020 targets set out in the 2011 Pan-Canadian
hypertension strategy
2007-2009 2010-2011 2012-2013 2020 Target
Hypertension Prevalence 19.6% 21.8% 22.6% 13%
Awareness of condition 83.4% 82.9% 84.3% 95%
Diagnosed with hypertension with 8.5% 11.1% 6.6% 40%
normal BP while not on
antihypertensive drug treatment a
(i.e. lifestyle control of
hypertension)
Appropriate drug therapy 79.9% 79.2% 79.6% 87%
Blood pressure under control 65.9% 64.1% 68.1% 78%

There are recommendations to national and regional government to improve performance

against these targets. This includes calling for a national physical activity strategy, a national
healthy food policy and better implementation of the 2010 Sodium Reduction Strategy and
for established and effective community programmes (such as CHAP) to be scaled up and
sustained as well as new programmes to be developed for deprived and hard to reach
groups.
For more detail about the evidence published about this programme see the case study in
Appendix 11.

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United States: Million Hearts
In 2012 the Million Hearts initiative was established by the US Department of Health and
Human Services, the Centre for Disease Control and Prevention (CDC) and Centres for
Medicare and Medicaid (CMS). This national initiative had a first phase, five year goal, of
preventing 1 million cardiovascular events by 2017, and is now in its second phase, Million
Hearts 2022.
Million Hearts works to align CVD prevention efforts across 50 states and 120 partners in the
US by focussing on a small set of evidence-based priorities selected for their impact on heart
disease, stroke and related conditions.
Promoting clinical quality improvement such as the implementation of the ABCS approach to
CVD management (Aspirin when appropriate, Blood pressure control, Cholesterol
management, and Smoking cessation) and meaningful use of health tools and technology
such as electronic records for identifying and monitoring patient groups are key activities.
Community approaches include introducing policies to eliminate artificial trans-fat intake,
reduce tobacco use and reduce sodium intake. The approaches of the partners involved with
Million Hearts cover levels 2,3 and 5 of the socio economic model.
Million Hearts 2022 continues these activities but with a new emphasis on achieving 70%
participation in cardiac rehabilitation by 2022. Key to achieving these aims are:
 Health care teams prioritise detection, treatment and control and review data
regularly to keep on track
 Using technology that includes decision support, patient portals, registries, and
algorithms to find gaps in care
 Processes around treatment protocols, proactive outreach and finding patients with
undiagnosed high BP, cholesterol or tobacco use
 Patient and Family Supports – training in home BP monitoring, problem solving in
medication adherence, counselling on nutrition, physical activity, tobacco use,
referral to community-based physical activity programs and cardiac rehabilitation.
 Health care professionals and health care organisations promote activities that
reduce the likelihood of CVD such as increased physical activity, healthy eating and
smoking cessation.

The core team, funded through CDC, works to distribute funding and support networks of
partners, and information gathering. Partners join the network because they have a common
aim to reduce the risk of CVD.

Organisations can apply for funding from Million Hearts for short term projects to implement
an initiative that the organisation will sustain after this time. This funding tends to be for
innovative projects such as helping health centres use their clinical data to identify potentially
hypertensive patients, or work to improve numbers of people monitoring their own blood
pressure. Funding can also be secured by taking part in the Medicare electronic health
record incentive programme that encourages meaningful use of health records to identify
people at risk of CVD and taking part in the ABCS challenge which rewards health care
providers who achieve the overall 70% target.

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Table 3: Progress towards Million Hearts ABCS and sodium intake targets
Measure 2005/06 2007/8 2009/10 2011/12 2013/14 2015/16
Aspirin use in people aged >40 NR NR 81.1% NR NR NR
(target 70%)
Blood pressure control 43.4 48.4 53.4 51.9 54.0 57.7*
Population level (target 65%)
Cholesterol control with statins – 44.1 49.4 49.7 54.2 56.8* 59.9*
% statin use among adults for
whom its recommended (target
70%)
Smoking – prevalence (%) of 28.2 26.9 26.2 25.1 24.0 23.0*
current combustible tobacco use
among adults (target 23%)
Mean sodium intake among 3,697 3,595 3,594 3,618 3,534 3,525
adults (mg/day) (target
2,900mg.day)
*projected figures, NR=not reported

Features of practices and health systems that achieved high levels of ABCS and
hypertension control include:

 Using multiple strategies to achieve high BP control rates aligned with the World
Health Organization’s Innovative Care for Chronic Conditions recommendations, and
strategies recommended by the Centers for Disease Control and Prevention funded
State Public Health Actions grantees and Million Hearts
 Having electronic health records with features such as electronic prescribing, patient
registries, and clinical decision support tools
 Implementing hypertension treatment protocols. This helps standardize and
coordinate care and facilities a team approach to BP management
 Some practices were offered financial and other incentives to clinicians and patients
to encourage greater attention to BP control by health insurers
 Engaging patients in BP home monitoring to assess progress, inform decision
making, and encourage adherence to treatment regimens.

For more detail about the evidence published about this programme see the case study in
Appendix 12.

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Key features of a successful CVD programme
The key features of what makes a successful CVD prevention programme has been known
for some time. The paper from the 33rd Bethesda conference of preventative cardiology held
in 2001 published a checklist of strategies27 which the authors suggested may result in a
successful CVD prevention programme (Table 4). This is split into strategies aimed at
optimising treatment and one to one support for lifestyle change for those at high risk of a
first or subsequent CVD event or diagnosis (strategies 1 to 10) and those which are aimed at
awareness raising of CVD risk, and encouraging community level changes (11 to 21). From
the information gathered from peer reviewed publications, interviews and the marketing of
the programmes on the internet a brief assessment was made about which strategies each
of the programmes employed. The information gathered was not exhaustive so in some
cases we may not know if particular strategies were used by some programmes.

Of the five programmes that focused on people with high risk conditions, COACH is
employing the greatest number of strategies (9/11) that might increase the likelihood of a
successful programme whilst ESCAPE were employing the fewest (2/11). DEHKO (7/11)
and the vascular risk programme (6/11) and Hypertension Canada (5/11) employed some
but not all of the strategies considered important for success.

Of the five community programmes, CHAP employs all 11 strategies whilst HONU and
Franklin both employ 10/11 of the strategies which might confer success. Million Hearts
utilise 7/11 and the particular case study initiative from Healthy Japan 21 employed 4/11 of
the strategies.

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Table 4: Strategies that may contribute to successful implementation of community CVD prevention programs (Ades et al 2002)

CVD prevention programme strategies for patient groups at high risk of a first or COACH ESCAPE DEHKO Vascular Hypertension
subsequent CVD event or diagnosis risk Canada

1 Have an enduring, consistent vision and mission   

Be flexible in goals and objectives  

2 Integrate three health models: medical, public health, and health promotion    

3 Strive to make enduring changes in systems, policies, and environment: to have 

a lasting impact

4 Continually improve quality: Design - Implement - Measure -Redesign  

5 Go where the people are  

6 Focus on continuous tracking, follow-up, and improvement of modifiable risk    

factors among individuals and populations at risk for preventable adverse
outcomes

7 Adhere to national guidelines; synchronize with national movements and topics     

8 Facilitate supportive, strong 3-person teams: patient, physician, professional  

nurse or other counsellor

9 Produce best results by deploying teams of physicians and non-physicians using   

multiple intervention modalities to deliver individualized advice on multiple
occasions

10 Promote integration of the community programme with primary medical care 

and community resources

International CVD Prevention Case Study Report Page | 40

 CHAP Healthy Franklin HONU Million
Japan 21 County Hearts

CVD prevention programme strategies for whole populations aimed at awareness

raising and community based change

11 Promote community ownership and openness to change   

12 Mobilize, collaborate, network, and integrate with key stakeholders and     

community resources

13 Employ multiple interventions through multiple channels: school, workplace,     

health care, community

14 Develop and participate with coalitions: local, regional, state, and/or national    

15 Identify and nurture local health professional and community champions     

16 Nurture local media advocacy   

17 Know your community, and modify general principles to deal with local realities,     
including cultural and resource issues. One size does not fit all

18 Seek reliable, long-term funding, immune from legislative and economic vagaries   

19 Try to make financial and behavioural vectors point in the same direction   

20 Enable and reward health-promoting behaviour’s by individuals and organizations     

21 Promote concept that community hospital has service-area responsibility for   

health promotion and disease prevention and management, in addition to acute
treatment

International CVD Prevention Case Study Report Page | 41

6 Discussion
The 10 programmes used as case studies in this report all found some success in their
application of a broad community based prevention approach and/or interventions to detect
and manage people diagnosed with CVD or at a high risk of CVD developing. Interestingly,
among all the case studies and indeed the wider list of programmes initially identified, none
stood out as having a truly innovative approach. Indeed innovation was not an important
factor in the success of the programmes, but rather developing a tried and tested approach
that successfully engaged relevant stakeholders, that could be sustained in the long term
and readily transferred and tailored to other communities, appears to be more important.

Ades et al (2002) considered that the thoughtful systematic application of interventions and
sustaining programme momentum, particularly in the face of economic decline, remained a
major challenge. Whilst all the case studies used some strategies included in the checklist in
Table 4, not all of the programmes have become sustainable and made the transfer to other
communities. However, three programmes, CHAP, COACH and HONU, employed the most
strategies and also focussed on sustainability. COACH and CHAP also focused on
applicability to other populations.

All the programmes employ some elements that Ades et al (2002) propose contribute to a
successful CVD prevention programme. For CVD prevention to be successful it helps if 1)
people are aware of the need and possibilities in relation to CVD reduction, 2) those at
particular risk are detected and their risk factors are identified, and 3) strategies for reducing
those risks are effective. Useful learning points from the case studies are discussed below in
relation to these three headings.

Whole population approach to raising awareness and changing lifestyle

A whole population approach to raising awareness is important as a first step to reducing
CVD and to reaching the maximum number of people. Several case studies were built
around a whole population approach and this was most clearly described in the literature by
the HONU project although there were descriptions of community centred population
approaches with the Health Japan 21, Franklin County and DEHKO case studies.

The HONU project looked at a small community and applied a multifaceted approach to
impact lifestyle and the development of healthy behaviours. HONU employed all 11
community strategies (numbers 11 to 21) from Table 4. An overarching steering group
comprising representatives from local government, large employers, chamber of commerce,
local health services, public health, schools, supermarkets and restaurants developed a
strategy to improve the health of their community. From this steering group 11 action teams
are formed who plan and implement initiatives specific to the need of their community across
all sectors. Each person on the steering group has their role written into their job description
by their employer so when anyone moves to a different job there will be a replacement on
the steering group. The steering group is also responsible for raising funding for initiatives
either by applying for national or regional funding for specific projects or raising it within the
community. Volunteers from the community were key to implementing the initiatives. The
initiatives involved activities in all sectors of the community for example; families invited to
the school domestic science rooms for cookery classes and taste testing; a range of school
based challenges for children; the offer of workplace lifestyle change courses lasting 6 to 8

International CVD Prevention Case Study Report Page | 42

weeks; workplace health assessments and heart screenings; a range of community based
events; food outlet challenges to improve healthy options offered to people and working with
national planning experts to make safety recommendations in the streets and built
environment.

This model could be an option in UK rural areas or towns where the town or district council
was keen to make a difference and where all key stakeholders could be represented. The
leadership group for each community could report into the town or district council and from
there to the local Health and Wellbeing Boards via public health teams. Well organised
communications and strong leadership from all sectors of the community were seen as key
elements to the success of the programme.

HONU was successful because there was very strong community engagement and
mobilisation and the community felt empowered to make changes that worked for them. This
empowerment in part was put in train by the initial research funding and a clear focus on
sustainability and incorporating the work into the mainstream business of the community.

Local authorities in England have a key role to develop strategy and facilitate health
improvement in the community and individually may be more or less successful in employing
some or all of the community strategies in Table 4 (numbers 11 to 21).

A focus on school and workplace support for people to undertake activities to help reduce
CVD risk factors would be helpful. There is some guidance for the NHS as an employer
(NICE, 2015) about creating healthy NHS workplaces but there could be more focus on
implementing the guidance for the benefit of employees. Some workplaces have developed
their own initiatives, giving out step counters to encourage more physical activity and offering
bike to work schemes. Overall, there is a lot of potential to develop workplace schemes
further to encourage health education sessions, physical activity, healthy eating options and
healthier ways to undertake desk based work such as standing desks and treadmill
workstations. For schools there are some marketing and teaching resources available for
teachers and some support from Sport England and the Youth Sport Trust to help people
achieve in sport however there may be other ways physical activity can be built into the
school day and a stronger focus on healthy eating and preparing healthy food across the
year groups.

It will be interesting to see the outcomes of the ‘Building Healthy Partnerships’, initiative in
eight sites in England, where funding is provided to enable Sustainability and Transformation
Partnerships (STPs) to engage with people in the community and the Voluntary, Community
and Social Enterprise (VCSE) sector to determine wellbeing and self-care priorities locally.
The self-care programme has a dual focus combining relationship building with agreeing and
implementing joint action and runs from April 2017 to June 2018.28

Detection of people with high risk of CVD

Detection of people with either a high risk of CVD or risk factors that could be improved by
lifestyle change (e.g. hypertension) in England is primarily in an NHS setting through
presentation with symptoms, GP case finding, the NHS health check and results from tests
taken during a hospital visit. A pilot by BHF to test wider models of delivering blood pressure
testing within the community is in the process of being implemented. This includes
community assets such as pharmacies, barber shops, football clubs, libraries, community

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centres and via partnering with other initiatives such Fire & Rescue Service Safe & Well
programmes. Two national case studies Million Hearts and Hypertension Canada were
focused on the detection of people with a risk of CVD through the health system by
education and training of health professionals, development of credible evidence based
guidance, facilitating the collaboration of partner organisations and in the case of Million
Hearts, financial incentives. Detection of CVD risk has improved in areas where there have
been financial incentives to make meaningful use of electronic health records. Some
elements of these initiatives are utilised in England such as using algorithms to identify
people at risk of CVD and the development of evidence based guidelines.

Many of the case studies, CHAP in Canada, HONU and Franklin County in the US, DEHKO,
in Finland, Healthy Japan 21, Hypertension Canada and Million Hearts aimed to identify
people in communities with a high risk of CVD and those with risk factors that could be
improved by lifestyle change. The promotion and implementation of an annual health check
by employers in Japan with financial incentives for high uptake, leads to a programme that
tracks most of the population every year. This top down approach can lead to employers
using the information to make work related decisions about employees depending on their
health check result and engagement with interventions offered.

Some elements of the Japan model may be less generalisable to a UK context, such as the
sharing of test results and subsequent actions with employers. A model more obviously
applicable to the UK is the one developed in Canada (CHAP). It is a community-driven and
community-owned initiative designed to be a scalable service that minimises centralised
support over time to achieve a long-term sustainable service. The basic premise is that if
people can be encouraged to come to community settings where volunteers can help them
take their blood pressure and ask them about their lifestyles to assess CVD risk in a
systematic way, then it is an opportunity to raise awareness about what their results mean
and how they can reduce their CVD risk. In this way all adults in the community can get to
know their numbers whilst detection of those at high risk of CVD and referral will improve.

This initiative ran clinics out of pharmacies who had signed up to participating in the
programme. Volunteers were recruited and trained by a nurse coordinator and clinic
sessions were held in pharmacies in rotation. In addition to education about CVD risk
factors, people have a CVD risk assessment using a questionnaire and they are assisted by
volunteers to take their own blood pressure using an automated monitor. Those meeting the
criteria for high risk of CVD and requiring treatment are referred to their GP. Those who
need to change lifestyle in order to reduce CVD risk factors are given information about what
community resources are available. The target population for the programme were those
aged ≥65 and volunteers were aged matched to this group. All those aged ≥65 were invited
to go to a session personally by the GP practice, a strategy known to elicit a higher
participation rate which is also used in the UK to invite people to take up the offer of NHS
screening (e.g. cervical, breast and bowel screening). However any adult could attend the
sessions which were advertised in the community. The CHAP model has been applied to
different communities with different requirements with the core principles being:

 Go to the people in the community

 Risk factor detection in the community is non-medicalised (i.e. do-it-yourself with help
from trained volunteers) but there are clear protocols and routes into a health care
setting when necessary

International CVD Prevention Case Study Report Page | 44

  Education, detection and signposting to community resources happen within the risk
factor detection sessions
 Use of peer volunteers where possible.

This case study illustrates how it can be beneficial to use wider professional groups and lay
people to deliver interventions whilst also linking the programme into primary care. This
model could be used within England, commissioned by the existing Local Authority and
Clinical Commissioning organisations or Accountable Care Systems (ACS) that are coming
on line. The service would be run by a small team such as a nurse co-ordinator and
administrative support who would run the programme by:

 Recruiting pharmacies
 Recruiting and training volunteers
 Engaging the support of GP practices
 Helping run clinics
 Ensuring referrals of people with high risk of CVD were made to the relevant GP.

This is certainly feasible in England and the generic model has been employed successfully
in communities in Canada, the Philippines, in Asian communities and rural communities.

Prevention for people at high risk of a first or subsequent CVD event or diagnosis.
For people who have been identified with a high risk of a first or subsequent CVD event the
most common intervention described by the case studies was the delivery of and training of
clinical staff in one to one or group counselling and motivational interviewing. DEHKO and
Healthy Japan 21 both focussed on delivering lifestyle counselling and motivational sessions
to educate and encourage people to make lifestyle changes either as individuals or in group
settings. The Vascular Risk Management programme supported patients who had had a
CVD event with a one hour session with the vascular nurse to identify where their CVD risk
could be reduced. Patients were encouraged to make changes to their lifestyle, self monitor
and record results and changes in CVD risk factors over a period of time. A website was
developed as a resource for patients and they were able to contact the nurse and ask for
advice by email. ESCAPE focused on one day of GP training and how that translated in a
change of patient management in terms of systematically talking to patients about exercise,
diet and adherence to drug treatment and tracking changes in patient CVD risk factors. Two
national case studies Million Hearts and Hypertension Canada both emphasised training of
health professionals and adherence to guidelines. Million Hearts aimed to improve clinical
quality by choosing a limited number of evidence based interventions known to make a
difference (ABCS). They then worked with partner organisations to ensure the agreement of
standards, and the addition of data items to national data sets for surveillance and research
purposes. To ensure progression towards the standards financial incentives to meet targets,
short term funding of projects and fostering collaboration between partners has been
important.

The COACH approach has been used extensively in Australia and has the most evidence of
all the case studies with two decades of reporting on clinical and cost effectiveness. It has
been used for a range of chronic conditions but also for people at risk of developing chronic
conditions who already require medication such as people with hypertension. Once a
condition has been diagnosed, the aim of COACH is to ensure that a nurse works with the

International CVD Prevention Case Study Report Page | 45

patient to educate and identify the areas of CVD risk that can be reduced. These could be
losing weight, increasing physical activity or empowering the patient to query their
medication with the GP if it does not follow national guidance.

A combination of the COACH programme where trained nurses support patients with phone
coaching and training for GPs similar to the ESCAPE case study might be a helpful
combination of initiatives to implement together. The continuing professional development
(CPD) would help refresh GPs understanding of the current UK guidance and available
prevention tools and COACH would introduce patients to self care, lifestyle change
resources, monitoring and understanding their medication. In this way the communication
between patient and GP may be more useful and support the initiative around Making Every
Contact Count in England. This would enhance the effectiveness of primary care in
facilitating patients to adhere to their medication and put in place strategies to make lifestyle
changes to reduce future CVD risk.

This approach could be commissioned by CCGs or the Accountable Care Systems that are
currently emerging in England, with CPD being offered in ways that are as accessible as
possible.

7 Conclusion
The case studies described in this report offer alternative models to CVD prevention than
those currently implemented in England. All the case studies showed some success in
reducing CVD risk factors but some programmes were more applicable and likely to be
sustainable in a UK setting than others. The most successful three programmes identified
here from the evidence available (HONU, CHAP and COACH) all have a very strong
community focus although they are targeting different elements of prevention. They are
using schools, workplaces, community centres, pharmacies, or peoples own homes to
deliver the programme. HONU has the broadest approach drawing on all sectors of the
community, whilst CHAP has a more focused approach running community clinics to detect
CVD risk factors in the local population and COACH offers support in management of risk
factors by phone to people in their own homes. Going to where the people are, empowering
individuals and the wider community with information and an understanding of CVD risk, that
they can monitor themselves, is clearly important in the success of the programmes.

All three programmes built in mechanisms for ensuring that they were sustainable in the long
term with minimal continued investment which is a particularly important consideration, given
the constraints of resources at the current time. Those case studies that were able to
achieve this, while at the same time succeeding in reducing CVD risk, are arguably the most
likely to be usefully adapted for use in England and the wider UK. They were also the case
studies that focused on long term sustainability from the outset, and we suggest that this
should be central to implementation of any changes that follow from this work in the UK.

One point that comes out strongly from many of the case studies is the large amount of
overlap between prevention of CVD and other long term non-communicable diseases, and
the fact that improvements in CVD prevention have the potential to impact on other diseases
that are currently major causes of morbidity and mortality in the UK, such as diabetes,
dementia and cancer.

International CVD Prevention Case Study Report Page | 46

International CVD Prevention Case Study Report Page | 47
8 Appendices
Appendix 1: Framework for information gathered for CVD prevention case studies from interviews and programme documentation
Elements of model by Questions
Van Olmen et al (2012)
1 Goals and outcomes What are the goals and outcomes of the intervention? (e.g. Raised awareness, Reduced mortality or
morbidity, reduction of variation in risk factors such as blood pressure, clinical effectiveness - are the
changes in outcomes recorded and if so what are they, maximise return to shareholders)
2 Values and principles What are the driving values and principles of the organisation putting the programme in place? (e.g.
equity, sustainability, choice, autonomy, security and protection; efficiency and effectiveness;
maximization or optimization)
3 Service delivery What is/was the time frame for the programme? (e.g. Fixed or ongoing, length of fixed programme, any
follow up)
What is the type of intervention and mechanism? (e.g. Health promotion local, mass media, health
checks/screening (direct invitation to individuals, opportunistic testing), pharmaceutical treatments, case
finding)
4 The population Is the intervention targeting a broad or narrow population? (Local or national level, size of target
population, geography, characteristics of population/population sub group – all adults or those with specific
high risk factors specific conditions , behavioural and/or medical risk factors)
5 The context How does the approach of the programme fit with the overall CVD risk in the population?
Is this programme part of a wider suite of programmes (focussed on individual, relationship,
community, society)?
6 Leadership and Who is signing off the project? (e.g. National CVD lead, Insurance company, Public health lead, Hospital
governance Medical Director)
How is governance of implementation and running of the programme achieved (e.g. steering group,
to what level?)
Have any safety issues been flagged?

International CVD Prevention Case Study Report Page | 48

 Is there any formal quality assurance to ensure agreed standards are met?

7 Finances How was the intervention funded (e.g. private investment, local health commissioners, National
commissioners, Charitable)
8 Human resources Who delivers the function? (e.g. primary care physicians, nurses, consultants, local public health teams,
pharmacies, national programme staff
9 Infrastructure and supplies Are there significant back office functions? (e.g. to organise lists of people to contact, mail out
invitations to people to participate, is there any specific equipment needed? (e.g. Blood pressure monitors,
ECG machines)
Where and how is the intervention delivered (setting)? ( e.g. Clinic room in GP surgery or hospital
outpatients or ward, Community pharmacy, Village hall, phone, community centres, shopping centres,
events e.g. football matches)
10 Knowledge and Did the workforce and or volunteers need training and what for
information
How are outcomes collated and performance monitored ( e.g. locally, standard national template
collated at programme level, not at all)
Is there any monitoring about what happens to patients next?

Was cost effectiveness measured and if so how?

Was an evaluation published and or is it ongoing?

International CVD Prevention Case Study Report Page | 49

Appendix 2: Socio ecological model and the influencers on health status with examples of policy, strategy, guidance and media
campaigns used in England to promote CVD prevention
Influencers on health status Policy/guidance/toolkit/media Hyperlink
campaign
Individual
Awareness or accurate PHE marketing campaigns, featuring https://campaignresources.phe.gov.uk/resources/campaigns
understanding of risk factors 28 campaigns, 18 of which are linked
to CVD prevention

Social Marketing Strategy, 2017 to https://www.gov.uk/government/uploads/system/uploads/attachment_data/fil

2020. Sept 2017, PHE e/646715/public_health_england_marketing_strategy_2017_to_2020.pdf

Accessible format of Making health and social care https://www.england.nhs.uk/wp-content/uploads/2015/07/access-info-upd-

information for individuals information accessible. Update July july-15.pdf
2015, NHS England

Individual attributes, e.g. This Girl Can. Sport England http://www.thisgirlcan.co.uk/

gender, ethnicity, age, mental
and physical capability and
impact on approach to lifestyle
change
Access to information about Change4life. PHE https://www.nhs.uk/change4life
how to change behaviour

One You! PHE https://www.nhs.uk/oneyou

Understanding your own risk Heart Age Test – How Healthy is Your https://www.nhs.uk/conditions/nhs-health-check/check-your-heart-age-tool/
Heart? NHS Choices

One You! PHE https://www.nhs.uk/oneyou

International CVD Prevention Case Study Report Page | 50

Family, peers and work
colleagues
Accurate information at the Your Babies Health and Development https://www.nhs.uk/conditions/pregnancy-and-baby/baby-reviews/
start of family life about Reviews. Details of routine checks and
healthy lifestyles reviews for babies. NHS Choices

Social Marketing Strategy, 2017 to https://www.gov.uk/government/uploads/system/uploads/attachment_data/fil

2020. Sept 2017, PHE e/646715/public_health_england_marketing_strategy_2017_to_2020.pdf

Work place colleagues views Workplace Challenge. National https://www.bhf.org.uk/health-at-work/inspire-workplace-health/physical-

about taking up work place programme to engage workplaces in activity/workplace-challenge
challenges sport and physical activity, Chartered
Society of Physiotherapists Network &
British Heart Foundation

Local organisations
Local health services capacity Cardiovascular disease: risk https://www.nice.org.uk/guidance/cg181
and capability to optimise CVD assessment and reduction including
detection and management lipid modification. Updated Sept 2016,
NICE Guidance

NHS Diabetes Prevention Programme. https://www.england.nhs.uk/diabetes/diabetes-prevention/

NHS England, PHE, Diabetes England

NHS Health Check https://www.nhs.uk/conditions/nhs-health-check/

NHS Diabetic Eye Screening: https://www.gov.uk/guidance/diabetic-eye-screening-programme-overview

Programme Overview. Updated Feb
2017, PHE, Guidance

Summary of Changes to QOF 2017/18 http://www.nhsemployers.org/-/media/Employers/Documents/Primary-care-

– England. Quality Outcomes contracts/QOF/2017-18/201718-Quality-and-outcomes-framework-summary-
Framework for detection and of-changes.pdf

International CVD Prevention Case Study Report Page | 51

 management of CVD within primary
care

GRASP-AF. Quality improvement tool https://www.nottingham.ac.uk/primis/tools-audits/tools-audits/grasp-af.aspx

to help GPs interrogate their clinical
data and assist in management and
care of patients with AF and at risk of
stroke. Primis, University of
Nottingham

High Blood Pressure: Plan and deliver https://www.gov.uk/guidance/high-blood-pressure-plan-and-deliver-effective-

effective services and treatment. services-and-treatment
Updated Mar 2015. PHE, Guidance

Preventing ill health: Commissioning https://www.england.nhs.uk/publication/preventing-ill-health-cquin-

for Quality and Innovation (CQUIN) supplementary-guidance/
supplementary guidance. August
2017, NHS England, Guidance.
Addressing risky behaviours with a
focus on alcohol consumption and
smoking

Social prescribing by GPs http://www.nhsalliance.org/wp-content/uploads/2015/10/Making-Time-in-

General-Practice-FULL-REPORT-01-10-15.pdf

Employers engagement and One You! https://campaignresources.phe.gov.uk/resources/campaigns/44-one-

promotion of healthy you/resources
workforce
Creating healthy NHS workplaces: A http://www.nhsemployers.org/-/media/Employers/Documents/Retain-and-
toolkit to support the implementation improve/Health-and-wellbeing/Creating-healthy-workplaces-toolkit.pdf
of the NICE workplace guidance, Sept
2015, NHS Employers, Toolkit

International CVD Prevention Case Study Report Page | 52

Schools engagement in healthy School Zone. Marketing and teaching https://campaignresources.phe.gov.uk/resources/campaigns/40-school-zone
activities, education and resources for teachers, school nurses
challenges. and parents, PHE.

School Games. Supports young people https://www.yourschoolgames.com/

to compete and achieve in sport at
school. Sport England & Youth Sport
Trust

Community
Local authority health Local health and care planning: Menu https://www.gov.uk/government/publications/local-health-and-care-planning-
promotion plans of preventative interventions. menu-of-preventative-interventions
Updated Feb 2018, PHE, Guidance

Clinical Commissioning Groups Cardiovascular disease data and https://www.gov.uk/guidance/cardiovascular-disease-data-and-analysis-a-

analysis: guide for health professionals guide-for-health-professionals
Guidance aimed at commissioners and
service planners. Updated Feb 2018,
PHE, Guidance

CVD Prevention Pathway. Shows https://www.england.nhs.uk/rightcare/products/pathways/cvd-pathway/

improvement potential specific to
each community. Updated Nov 2016,
RightCare, NHS England

Food outlets and limited Healthier catering guidance for https://www.gov.uk/government/uploads/system/uploads/attachment_data/fil

offering of healthy options different types of businesses – tips on e/604934/Healthier_catering_guidance_for_different_types_of_businesses.pdf
including cafes, restaurants, providing and promoting healthier
retail businesses, community food and drink for children and
facilities such as leisure centres families. Mar 2017, PHE, Guidance

Strategies for Encouraging https://www.gov.uk/government/uploads/system/uploads/attachment_data/fil

Healthier ‘Out of Home’ Food e/604912/Encouraging_healthier_out_of_home_food_provision_toolkit_for_lo

International CVD Prevention Case Study Report Page | 53

 Provision: A toolkit for local councils cal_councils.pdf
working with small food businesses.
Mar 2017, PHE, Toolkit

Limited green spaces or lack of Local Action on Inequalities: Improving https://www.gov.uk/government/uploads/system/uploads/attachment_data/fil

perceived safety in available access to green spaces. Sept 2014, e/355792/Briefing8_Green_spaces_health_inequalities.pdf
green spaces, PHE

Built environment not Spatial Planning for Health: an https://www.gov.uk/government/publications/spatial-planning-for-health-

conducive to walking, cycling, evidence resource for planning and evidence-review
or other physical activity designing healthier places. July 2017,
PHE
Community facilities available A guide to community-centred https://www.gov.uk/government/publications/health-and-wellbeing-a-guide-
for health and wellbeing approaches for health and wellbeing. to-community-centred-approaches
activities Feb 2015, PHE

Community challenges One You. Resources to support https://campaignresources.phe.gov.uk/resources/campaigns/44-one-

implementation of community you/using_the_brand2
challenges, case studies for ‘using the
brand’ around England

Moving to more active travel Working Together to Promote https://www.gov.uk/government/uploads/system/uploads/attachment_data/fil

Active Travel: A briefing for local e/523460/Working_Together_to_Promote_Active_Travel_A_briefing_for_local_
authorities. May 2016, PHE authorities.pdf?utm_source=The%20King%27s%20Fund%20newsl

National
Food industry approach to Sugar Reduction: Achieving the 20%. A https://www.gov.uk/government/publications/sugar-reduction-achieving-the-
health to reformulation of technical report outlining progress to 20
foodstuffs date, industry guidelines, 2015 sugar
baseline levels in 9 food categories
and next steps. Mar 2017, PHE

Salt reduction: targets 2017. Mar https://www.gov.uk/government/publications/salt-reduction-targets-for-2017

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 2017, PHE

Calorie reduction: the scope and https://www.gov.uk/government/publications/calorie-reduction-the-scope-

ambition for action. Evidence on and-ambition-for-action
children’s calorie consumption and
details of the calorie reduction
programme, principally for the food
industry and public health bodies.
Mar 2018, PHE

Political will to legislate about Improving lives: the future of work https://www.gov.uk/government/uploads/system/uploads/attachment_data/fil
food, built environment, health and disability. Nov 2017, DWP e/663400/print-ready-improving-lives-the-future-of-work-health-and-
alcohol, and tobacco smoking & DoH disability.pdf

Tobacco control laws: Analysis of https://www.tobaccocontrollaws.org/legislation/country/england/summary

legislation and litigation from around
the world. Includes England summary,
updated Sept 2017

Nutrition legislation Information https://www.reading.ac.uk/foodlaw/pdf/uk-15019-Nutrition-Legislation-

Sheet. Oct 2015, DoH Info.pdf

Evidence based approach to Childhood obesity: a plan for action. https://www.gov.uk/government/publications/childhood-obesity-a-plan-for-

policy and guidance around Jan 2017, PHE, Guidance action
CVD risk factors
Government Dietary https://www.gov.uk/government/uploads/system/uploads/attachment_data/fil
Recommendations for energy and e/618167/government_dietary_recommendations.pdf
nutrients for males and females aged
1 – 18 years and 19+ years. Aug 2016,
PHE
Towards a smoke free generation: A https://www.gov.uk/government/publications/towards-a-smoke-free-
tobacco control plan for England. generation-tobacco-control-plan-for-england
Objectives to be achieved by 2022.

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 July 2017, DHSC

Alcohol: applying All Our Health. https://www.gov.uk/government/publications/alcohol-applying-all-our-

Details interventions, outcomes, health/alcohol-applying-all-our-health
indicators & guidance. Updated Feb
2018

The public health burden of alcohol: https://www.gov.uk/government/publications/the-public-health-burden-of-

evidence review. Impact of alcohol on alcohol-evidence-review
public health and the effectiveness of
alcohol control policies. Dec 2016, PHE

Action Plan for cardiovascular disease https://www.gov.uk/government/uploads/system/uploads/attachment_data/fil

prevention, 2017 to 2018. Sept 2017, e/648190/cardiovascular_disease_prevention_action_plan_2017_to_2018.pdf
PHE

Everybody Active, Every Day: https://www.gov.uk/government/uploads/system/uploads/attachment_data/fil

Implementation and Evidence Guide. e/353385/Everybody_Active__Every_Day_Implementation__Evidence_Guide_C
Sept 2014, PHE ONSULTATION_VERSION.pdf

Sporting Future – a New Strategy for https://www.gov.uk/government/publications/sporting-future-a-new-strategy-

an Active Nation. Dec 2015, cross- for-an-active-nation
government

High blood pressure: action plan. https://www.gov.uk/government/publications/high-blood-pressure-action-plan

How to identify, treat and prevent
high blood pressure. Jan 2018, PHE,
Guidance

National public health Social Marketing Strategy, 2017 to https://www.gov.uk/government/uploads/system/uploads/attachment_data/fil

marketing strategy 2020. Collaborating with different e/646715/public_health_england_marketing_strategy_2017_to_2020.pdf
partners to add impact and reach of
initiatives taking into account current

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 changes in technology and digital
media. Sept 2017, PHE

National air pollution strategy Clean air strategy May 2018 https://consult.defra.gov.uk/environmental-quality/clean-air-strategy-
by Department of Environment National strategy, targets and actions consultation/user_uploads/clean-air-strategy-2018-consultation.pdf
Food and rural affairs to reduce air pollution and people
exposed to emissions between 2020
and 2030.
Construction industry approach Healthy New Towns network. https://www.england.nhs.uk/ourwork/innovation/healthy-new-towns/
to healthy environments Network to develop best practice,
case studies & guidance to help
ensure all new housing developments
embed certain principles, promoting
health and wellbeing and securing
high quality health and care services

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 Appendix 3: Australia COACH Programme

COACHING PATIENTS ON ACHIEVING

CARDIOVASCULAR HEALTH: THE COACH
PROGRAM®
A CASE STUDY

PROGRAMME AT A GLANCE
The COACH Program® (Coaching patients On Achieving
Cardiovascular Health) was developed in 1995 in Melbourne
and is currently available in all Australian states. This
prevention programme aims to reduce the impact of chronic
disease on the individual and health system.
The programme looks for ways to reduce future
cardiovascular disease (CVD) risk in those people already
diagnosed with CVD or at high risk of an event. The focus is
on lifestyle change and identifying ‘treatment gaps’ where KEY TAKEAWAYS
medication has not been optimised. Health professionals,
trained in the COACH system, mentor the patient on  Started as a research
changes in lifestyle and support them in working with their project before
usual doctor to ensure treatment is optimised for their expansion to public and
particular circumstances, based on national guidance in private healthcare
order to reach target levels for their modifiable risk factors. systems throughout
Australia and other
COACH is a structured telephone and mail-out health parts of the world
programme for people with chronic disease.
 Empowers and
There are five stages to each phone coaching session: supports individuals to
 Finding out what the patient knows: ask patients better manage their
questions to find out what they know about their risk chronic disease and the
factors and treatment for their risk factors associated lifestyle and
 Education: tell patients what they should know biomedical risk factors
 Patient empowerment: empower patients to ask
their own doctor(s) to measure their risk factors;  Delivered by health
provide them with their test results; prescribe professionals trained in
appropriate medication and alter doses/ drugs if the COACH system
appropriate
 Action plan: set an action plan to be achieved by the  Programme
next coaching session standardised across
 Monitoring: check what action has taken place since training, access to
the previous coaching session and use the Program software and
information as the basis for the next session generation of
performance data
The COACH Program runs for approximately six months
with telephone-based coaching sessions every four to six
weeks. At the end of each session a letter detailing the
topics discussed is sent to the patient and the doctor(s).
Patients receive a written information pack at the start of the
programme.

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 TARGET POPULATION
The programme targets people with In an analysis of private patients receiving
chronic disease and is available in the COACH in addition to usual care compared
public and private health care systems to usual care alone, there were:
throughout Australia.  Significantly fewer deaths in the
COACH group (absolute reduction
in all-cause mortality of 5%)
BENEFITS AND OUTCOMES  No differences in number of
A multicentre randomised controlled trial admissions, total days hospital stay
(n=792) has demonstrated greater and average bed days
improvements at six-months follow-up for
patients receiving COACH in addition to An analysis comparing private patients
usual care, compared to usual care alone: receiving COACH in addition to usual care
compared to usual care alone, found the
 COACH patients had significantly
average net cost impact over 6.35 years
better total cholesterol, LDL
follow-up was a saving to the insurance
cholesterol , BMI, saturated fat
company of $12,115 (£6,822) per person.
intake, proportion of patients taking
lipid-lowering drugs, a higher
proportion of people taking up
walking since discharge and lower PROGRAMME EXPERIENCES
anxiety levels
 Patients need four or five coaching
 There was no significant difference
sessions to make progress
at six months in HDL cholesterol,
triglyceride levels, blood pressure,
fasting glucose, smoking or  Coaches are all health
professionals including nurses,
depression score
dieticians, pharmacists,
Longer-term follow-up of RCT participants physiotherapists and occupational
has shown that improvements in risk factor therapists
status and adherence to medications
following COACH are sustained for 18  Full time coaches can take on 200-
months. For example: 250 new patients per year
 The percentage of patients
achieving the total cholesterol  COACH has been operating with
target was 27% before COACH, BUPA in the UK for five years and
57% immediately after COACH and has been adapted for UK guidelines
52% 18 months later
 The percentage of patients
undertaking physical activity was
70% before COACH, 94%
immediately after COACH and 92%
18 months later

A four-year follow up of RCT participants

has shown that four coaching sessions
over six months is associated with
significant reduction in:
 Any-cause hospital admissions (by
16%)
 Any-cause hospital bed days (by
20%)
 Cardiac bed days (by 15%)

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THE DETAIL
Context
The COACH Program® aims to empower and support individuals to better manage the
symptoms related to their chronic disease and the associated lifestyle and biomedical risk
factors and to reduce the impact of chronic disease on the individual and health system. The
COACH Program is currently available in all Australian states.

Goals, Values and Principles

The COACH Program looks at where there are modifiable CVD risk factors that can be
improved either by changes in lifestyle or optimising treatment and health coaches work with
patients to reduce those CVD risk factors so they can achieve national recommended target
levels while they work in partnership with their usual doctor. The COACH Program is ‘risk
factor outcome focused’.

The Queensland COACH Program describes the core components and distinguishing
features of the COACH Program as:

 Coaches always initiate contact with the patients for coaching sessions – the programme
does not depend on the patient contacting the coach
 Coaches identify where there are modifiable CVD risk factors which would improve with
lifestyle changes
 Coaches identify the ‘treatment gaps’ in each patient’s management – the gaps between
the national guideline-recommended care and the care patient’s actually receive
 Coaches educate, advise and encourage patients to close the ‘treatment gaps’ and
achieve guideline-recommended risk factor targets whilst working with their usual
doctor(s)
 Coaches encourage patients to work with their usual doctors to achieve the most
practical medication regimens possible, in order to facilitate lifelong adherence to
recommended medication

Targets are set for reducing modifiable lifestyle CVD risk factors and closing any ‘treatment
gaps’.

Population
The programme targets people with chronic disease. If a patient has more than one chronic
disease, they are coached on the risk factors for all their conditions. There is no age limit in
the current COACH Program.

Patients in the public health system are generally recruited in hospitals, but other referral
routes are possible. For example, in the Queensland COACH Program referrals are
accepted from all sources including public hospitals, general practitioners, medical
specialists, other health professionals, cardiac rehabilitation services, ‘Quitline’ (smoking
cessation) and self-referral. In the private health system, coaches use claims information to
identify prospective patients and ‘cold call’ patients who have recently been hospitalised for
chronic diseases. 99% of patients in public health systems and approximately 80% of
people in private health systems choose to participate in the COACH Program.

Conditions included in the COACH Program include heart failure, coronary heart disease,
hypertension, stroke, type 2 diabetes, pre-diabetes and COPD. The range of conditions
covered can vary between Australian states.

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Service Delivery
The COACH Program started in 1995 as a research project. In 2005 the COACH Program
was rolled out as standard care in the Victoria public health system. In 2006 a limited
company was formed to expand delivery and private health funds began using COACH from
2007. By 2009, the COACH Program was operating in the public health system in all
Australian states and the majority of private health funds and had expanded overseas to
Europe.

COACH is a structured telephone and mail-out health programme for people with chronic
disease. A health professional trained in the COACH Program coaches patients to achieve
and maintain the target levels for their modifiable risk factors and to take the recommended
medications, according to evidence-based guidelines. There are five stages to each phone
coaching session and the cyclical process illustrated in the figure below is repeated until the
target level is achieved.

In the current Queensland programme:

 Patients receive an information pack with their first letter about their chronic condition
 A nurse contacts the patient at an agreed time and delivers information and education to
help patients better manage their chronic disease. This includes discussion of biomedical
and lifestyle risk factors and setting targets based on guidelines for specific diseases
 The programme runs for approximately 6 months with a call every 4-6 weeks
 At the end of each telephone session, a letter detailing the topics discussed is sent to the
patient, the GP and/or their treating specialist
 Patients may contact their coach for advice and support between sessions

Figure 1: The five stages to each phone coaching session. The cyclical process is repeated
until the target level is achieved

Source: Vale M. Leading the world in coaching for prevention of chronic disease. Available from
https://www.health.qld.gov.au/__data/assets/pdf_file/0028/155197/coach-factsheet.pdf (Accessed February 2018)

Outcomes
The COACH Program was originally a research project and was initially evaluated in one
single centre and one multicentre RCT with associated studies following patients for two and
four years. Further published studies have looked at outcomes for COACH compared to
usual care for private patients, outcomes for public health system patients compared to
private patients and outcomes from the COACH Program in Queensland.

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A single centre RCT evaluation of the COACH Program (Vale et al 2002)
The study included patients with coronary heart disease who had been hospitalised for
revascularisation procedures who received the COACH Program plus usual care (n=121)
compared to usual care only (n=124). Usual care included encouragement to attend a
cardiac rehabilitation programme. Patients were excluded if they were >75 years or
unsuitable for intensive coaching e.g. immobilized by their condition. 75% of participants
were male. Only patients who provided follow-up data were included in the analysis (COACH
n=107; usual care n=112). Patients were coached to achieve and maintain a target level of
<4.5mmol/L.

 COACH patients had significantly lower total cholesterol levels at 6 months follow-up
compared to usual care patients (5.00mmol/L vs 5.54mmol/L, p=0.0001)
 31% of the COACH group achieved the total cholesterol target compared to 10% of the
usual care group (p<0.01)
 COACH patients had significantly lower mean LDL cholesterol than usual care at 6-
months follow-up (3.11mmol/L vs. 3.57mmol/L, p=0.0004)
 There was no difference in HDL cholesterol (1.12 vs. 1.16, p=0.4)
 The number of patients taking lipid-lowering drugs was similar in the 2 groups (63% vs
60%). There was also no significant difference in the dose prescribed
 A similar proportion of patients attended cardiac rehabilitation as part of usual care (53%
vs 50%)

A multicentre RCT evaluation of the COACH Program (Vale et al 2003)

This study included patients admitted to six hospitals for coronary artery bypass graft,
percutaneous coronary intervention, acute myocardial infarction or unstable angina (and
discharged on medical therapy) or coronary angiography with later planned elective
revascularisation. Patients were randomised to the COACH Program plus usual care
(n=398) or usual care only (n=394). 77% of the patients were men with a mean age of 58.5
years. 113 patients dropped out (67 COACH and 46 usual care). The analysis was intention-
to-treat.

At 6-months follow-up COACH patients compared to usual care only patients had:

 Significantly lower total cholesterol (4.48mmol/L vs 4.72mmol/L, p<0.001)

 Significantly more patients taking lipid-lowering drugs (94% vs 87%, p=0.002)
 Significantly lower LDL cholesterol (mean reduction 0.55mmol/L vs 0.21mmol/L,
p<0.0001)
 Significantly greater reduction in BMI (mean reduction 0.5 vs 0.1, p<0.001))
 Significantly greater reduction in saturated fat intake (mean reduction 8.0g vs 4.9g,
p=0.002)
 Significantly greater increase in people taking up walking since discharge (69% vs 44%,
p<0.0001)
 Significantly greater reduction in anxiety level (p=0.03)
 There was no significant improvement in HDL cholesterol, triglyceride levels, blood
pressure, fasting glucose, smoking behaviour or depression score
 A similar proportion of patients attended cardiac rehabilitation as part of usual care (53%
vs 57%)

A 2-year follow-up of COACH patients (Jelinek et al 2009)

656 patients with coronary heart disease who completed the six month COACH Program in
three hospitals were followed-up by telephone every six months for two years. Patients were
80% male, with a median age of 61 years.

Improvements in risk factor status and adherence to medications achieved after the COACH
Program were sustained for more than 18 months after completion of the programme.

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In table 1, all baseline to 6 months comparisons (before and after COACH) were statistically
significant (p<0.05) and all baseline to 24 month comparisons (except BMI) were statistically
significant (p<0.05).

Table 1: Baseline to 6 months comparisons (before and after COACH).

12 18 24
Baseline 6 months
months months months
Percent achieved total
26.9% 56.9% 51.9% 51.2% 52.1%
cholesterol <4.0mmol/L
Percent achieving target
26.1% 42.5% 39.6% 40.5% 39.7%
waist circumference
Percent not smoking 82.3% 94.5% 94.6% 94.5% 94.7%
Percent taking renin-
63.7% 74.7% 76.1% 76.1% 77.6%
angiotensin antagonists
Percent taking statins 88.0% 97.3% 96.3% 95.9% 94.4%
Percent undertaking
70.2% 94.0% 91.0% 92.3% 92.2%
physical activity
Percent achieving fasting
65.3% 80.7% 75.4% 75.2% 73.0%
blood glucose <6.1mmol/L
Percent achieving blood
75.2% 87.5% 81.2% 78.1% 80.0%
pressure <140/90mmHg
BMI<25kg/m2 21.2% 28.1% 26.2% 24.0% 23.6%

 There was no significant difference in the proportion of patients taking anti-platelet

agents (95% at baseline and 24 months)
 The percentage of patients taking beta-blockers reduced over time (from 73% to 65%)

A 4-year follow-up of COACH patients (Vale et al 2004)

A 4-year follow-up of the 792 patients in the multicentre COACH RCT found that four phone
coaching sessions over 6 moths (i.e. two hours of coaching time):

 Reduced any-cause hospital admissions by 16% compared to usual care (p<0.01)

 Reduced any-cause bed-days by 20% compared to usual care (p<0.001)
 Reduced cardiac bed-days by 15% compared to usual care (p<0.01)
 The reduction of 12% in cardiac hospitalisations compared to usual care was not
statistically significant

Case-control study on COACH outcomes from the perspective of a private health insurer
(Byrnes et al (in press)
This analysis included patients aged <85 with evidence from insurance claims of a CVD
diagnosis. Outcomes based on six years of insurance hospital claims were compared for
matched patients receiving COACH plus usual care and patients receiving usual care only.
Patients in the control group were not aware that there was an intervention group. 512
patients were included in each group and were matched for age, sex, relationship status and
prior hospital admission history (minimum 12 months history). The average age of
participants was 75 years and approximately 70% of each group were male.

Key findings at a mean of 6.35 years follow-up:

 There were significantly fewer deaths in the COACH group (21.9%) than the usual care
group (16.8%) (absolute reduction in all-cause mortality of 5.08% (95%CI -9.91 to -0.25,
p=0.04)
 There was a significant reduction in mortality for males receiving COACH compared to
usual care (hazard ratio 0.70 (95%CI 0.53 to 0.93, p=0.014). The difference for females
was not significant

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 There was a significant reduction in mortality for COACH patients receiving ≥4 coaching
sessions compare to usual care (hazard ratio 0.58 95%CI 0.42 to 0.81, p=0.001). The
difference for COACH patients who received ≤3 coaching sessions was not significant
 Outcomes for number of admissions per participant per month, total days of hospital stay
and average days of stay per hospital admission per participant favoured COACH
patients but there was no statistically significant difference compared to usual care

A comparison of results for public health system and private patients (Jelinek et al 2014)
Australian patients in private hospitals are usually of higher socio-economic status than
those treated in public hospital systems. This study compared outcomes for 2,266 patients
treated in in public hospitals in two states with outcomes for 3,278 patients from four private
health funds throughout Australia. The socioeconomic status of the two groups was
confirmed by postcode analysis.

Greater improvements in the risk factors occurred in the public health group than in the
private health group. These improvements were statistically significant for fasting blood
glucose, body weight, smoking, physical activity, total and LDL cholesterol and diastolic
blood pressure.

Table 2: Improvements in CVD risk factors public vs private health funding

Public Private
Before After Before After
COACH COACH COACH COACH
Total cholesterol (mmol/L) 4.4 3.7 4.2 3.6
Triglycerides (mmol/L) 1.5 1.3 1.3 1.1
LDL-cholesterol (mmol/L) 2.5 1.8 2.3 1.8
HLD-cholesterol (mmol/L) 1.0 1.1 1.2 1.2
Systolic blood pressure (mmHg) 121 120 125 124
Diastolic blood pressure (mmHg) 70 70 74 70
Fasting blood glucose (mmol/L) 5.5 5.3 5.3 5.3
HbA1c% (diabetics only) 7.5 7.0 6.9 6.8
Current smokers 19.5% 9.7% 2.4% 2.1%
Waist circumference (cm) 96.0 93 96.5 94
Weight (kg) 84 82 82 80
Alcohol consumption at target 78.3% 88.7% 75.7% 83.9%
Physical activity at target 45.4% 85.3% 54.6% 81.1%

Outcomes for the Queensland COACH Program (Ski et al 2015)

Outcomes for patients who completed COACH in Queensland were reported for coronary
heart disease (CHD) (n=1,962) and type 2 diabetes patients (n=707). Patients were coached
by registered nurses and 83% of the 3,235 patients who enrolled in COACH completed the
programme, receiving a mean of 5.5 sessions (standard deviation 1.2). The mean age of
CHD patients was 64 (69% male) and the mean age of diabetes patients was 60 (53%
male).

There were statistically significant improvements in mean (standard deviation) values

following COACH for all risk factors (p≤0.001) for both CHD and type 2 diabetes patients
(Table 3).

Table 3: Improvements in mean CHD and type 2 diabetes risk factors

CHD patients Diabetes patients
Before After Before After
COACH COACH COACH COACH

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Total cholesterol (mmol/L) 4.29 (1.27) 3.73 (0.96) 4.51 (1.26) 4.04 (1.02)
Triglycerides (mmol/L) 1.80 (1.84) 1.47 (0.97) 2.23 (1.84) 1.90 (1.24)
LDL-cholesterol (mmol/L) 2.44 (1.07) 1.83 (0.77) 2.46 (1.00) 2.04 (0.84)
HLD-cholesterol (mmol/L) 1.08 (0.35) 1.13 (0.34) 1.06 (0.30) 1.09 (0.30)
Systolic blood pressure 124.5 (16.3) 123.0 (13.3) 129.3 (15.7) 127.3 (12.8)
(mmHg)
Diastolic blood pressure 71.4 (11.0) 70.2 (9.2) 74.8 (9.9) 73.4 (9.5)
(mmHg)
Fasting blood glucose 5.55 (0.90) 5.41 (0.92) --- ---
(mmol/L)
HbA1c% (diabetics only) 7.83 (1.80) 7.41 (1.43) 8.15 (2.06) 7.45 (1.54)
Current smokers 296 222 139 105
2
BMI (kg/m ) 28.8 (6.0) 28.5 (5.8) 35.1 (9.5) 34.7 (9.1)
Weight (kg) 85.1 (20.2) 84.1 (19.5) 101.7 (28.5) 100.7 (28.1)
Alcohol (standard drinks per 1.4 (1.7) 1.1 (1.3) 1.3 (2.0) 0.9 (1.5)
day)
Physical activity (minutes/ 142.0 (170.3) 229.1 (238) 127.1 (197) 181.6 (177.1)
week)
The proportion of patients taking medications significantly increased after the COACH
programme for both CHD and diabetes patients (p<0.001).

Table 4: Proportion of people taking medications before and after the COACH
programme for CHD and type 2 diabetes.
CHD patients Diabetes patients
Before After Before After
COACH COACH COACH COACH
Statin 92% 93% 66% 78%
Beta-blocker 72% 72% 27% 28%
Antiplatelet agent 92% 93% 52% 59%
ACE inhibitor/ angiotensin receptor 77% 78% 63% 68%
antagonist

Leadership and Governance

COACH started as a research programme. A limited company was formed in 2006 and by
2009 COACH was being delivered in the public health system in all Australian states and the
majority of private health funds.

The COACH Program provides training and evaluation data for coaches, who are employed
by healthcare organisations.

In the Queensland COACH Program, coaches perform a minimum of 60 coaching sessions

per month to maintain competency. The Queensland Health Contact Centre conducts
monthly quality assurance of phone coach sessions and patient letters. Session letters are
reviewed by a trainer to ensure the documented advice follows the guideline
recommendations and that formatting, structure and messaging are consistent across

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trainers. A trainer reviews session call recordings with the coach during monthly quality
review sessions and rates sessions against a best practice matrix.

Finances
The programme is delivered in-house by participating healthcare organisations.

A private insurer analysed the cost impact for matched patients who underwent COACH plus
usual care (n=512) compared to usual care alone (n=512).

 The average COACH Program cost per participant was $592 (£333)
 The average net cost impact to the insurance company of the COACH Program
compared to usual care over a 6.35 year follow-up period was a saving of $12,115 per
person (£6,822)
 There was a significant difference in health care costs between COACH patients who
received ≥4 coaching sessions ($42,307; £23,826) and usual care patients ($61,725;
£34,754); a difference of $19,418 (£10,931) per person (p=0.006). This difference was
not significant for patients with ≤3 coaching sessions
 There was a significant difference in health care costs between male COACH patients
($47,680; £26,842) and male usual care patients ($66, 627; £37,509); a difference of
$18,947 (£10,667) per person (p=0.029). This difference was not significant for female
patients

(March 2016 costs, Australian dollars. Sterling costs calculated using March 2018 exchange
rate)

The use of the COACH Program in the public health system is funded by the state
government health departments.

The randomised controlled trials assessing the impact of COACH were funded by project/
research grants.

Human Resources
The programme is delivered by qualified health professionals trained in the COACH system.
Full time coaches can take on 200-250 new patients per year.

In the initial single centre study assessing the impact of the COACH Program, the first
coaching session was the longest in duration with a median time of 20 minutes (range 5 to
45). Subsequent coaching calls were a median of 10-11 minutes long (range 3 to 66).

In the multicentre study assessing the impact of the COACH Program the median duration of
the first coaching session was 30 minutes (range 6 to 200). The duration of subsequent calls
was 20 minutes (range 5 to 50).

Infrastructure and Supplies

The COACH Program is delivered by telephone. Participants are primarily recruited in
hospitals or through review of private claims data.

Knowledge and Information

Training
Nurses receive training in the application of the programme. The COACH Program provides
training, software and support for qualified health professionals (employed by healthcare
organisations).

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In Queensland, coaches have 2 weeks face-to-face training in the principles and practice of
the COACH Program and then undergo a 12-week preceptorship of intensive monitoring by
experienced coaches where coaches are checked against set criteria. Training and delivery
of the programme is standardised. Coaches are given continuing education when guidelines
change and based on areas for improvement identified through quality assurance and
programme evaluation.

Experienced coaches can undergo the ‘Train-the-Trainer Coach Course’ to become a trainer
of novice coaches and conduct quality assurance activities.

Data
The COACH Program Software Application provides all key performance indicator data on
the effectiveness of the programme. It includes patient baseline characteristics, patient
uptake, discontinuation rates, achievement of guideline-recommended biomedical and
lifestyle risk factor targets and adherence to guideline-recommended medications at entry to
and exit from the programme. Relevant medical guidelines are incorporated in to the
software application and are updated as guidelines change.

Organisations delivering the COACH Program receive six-monthly evaluation reports which
include comparison with the national mean. Results are provided for individual coaches and
organisations. The evaluation reports are used to review operations and improve the
outcomes within each organisation through a continuous quality improvement process.

The COACH Program software also produces written summaries of each coaching session
which are sent to patients and their doctor(s) and act as a record of progress. These are
structured with headings which address each risk factor with the actual result, recommended
treatment, target and whether the patient is meeting the target. Risk factor charts allow
patients to track their progress towards achieving their risk factor targets.

REFERENCES
 Byrnes J. Elliott T. Vale MJ. Jelinek MV. Scuffham P. Coaching patients saves lives
and money. The American Journal of Medicine. December 2017 (epub ahead of
print)
 Health Support Queensland. The COACH program® fact sheet. Available from
https://www.health.qld.gov.au/__data/assets/pdf_file/0028/155197/coach-
factsheet.pdf (Accessed February 2018)
 Jelinek MV. Santamaria JD. Best JD. Thompson DR. Tonkin AM. Vale MJ. Reversing
social disadvantage in secondary prevention of coronary heart disease. International
Journal of Cardiology 2014, 171: 346-350
 Jelinek M. Vale MJ. Liew D. Grigg L. Dart A. Hare DL. Best JD. The COACH
Program produces sustained improvements in cardiovascular risk factors and
adherence to recommended medications – 2 years follow-up. Heart, Lung and
Circulation 2009, 18: 388-392
 Ski CF. Vale MJ. Bennett GR. Chalmers VL. McFarlane K. Jelinek MV. Scott IA.
Thompson DR. MJA 2015, 202(3): 148-153
 Vale M. Leading the world in coaching for prevention of chronic disease. Available
from http://www.adma.org.au/Day1/Margarite%20Vale.pdf (Accessed February 2018)
 Vale MJ. Interview with SPH, February 2018
 Vale MJ. Jelinek MV. Best JD. Dart AM. Grigg LE. Hare DL. Ho BP. Newman RW.
McNeil JJ. Coaching patients on achieving cardiovascular health (COACH): a

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 multicenter randomized trial in patients with coronary heart disease. Arch Intern Med
2003, 163(22): 2775-2783
 Vale MJ. Jelinek MV. Best JD. Santamaria JD. Coaching patients with coronary heart
disease to achieve the target cholesterol: a method to bridge the gap between
evidence-based medicine and the “real world” – randomised controlled trial. Journal
of Clinical Epidemiology 2002, 55: 245-252
 Vale MJ. Sundararajan V. Jelinek MV. Best JD. Four-year follow-up of the multicenter
RCT of Coaching patients On Achieving Cardiovascular Health (The COACH study)
shows that the COACH Program keep patients out of hospital. Circulation 2004 110:
suppl. III-801

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 Appendix 4: Finland DEHKO And One Life

DEHKO – Development Programme for the

Prevention and Care of Diabetes

A CASE STUDY
PROGRAMME AT A GLANCE
DEHKO, was launched in Finland as part of the Finnish
National Diabetes Programme, established as a ten year
programme running from 2000 to 2010 and aimed to improve
self-care and prevent and reduce complications from type 2
diabetes. From 2011, the DEHKO programme expanded to
include raising awareness and reducing risk of non-
communicable diseases with common risk factors including
cardiovascular disease (CVD), dementia, chronic obstructive
pulmonary disease (COPD) and type 2 diabetes. This
programme ‘One Life’ is supported by a collaboration of the
Finnish Diabetes, Brain and Heart Associations and focuses on
supporting people to make lifestyle changes to improve
modifiable risk factors.

The principle elements of DEHKO are:

 Prevention of type 2 diabetes through:
o A whole population strategy of awareness KEY TAKEAWAYS
raising
o A high risk population strategy encouraging  The focus on risk
people to undertake a brief risk assessment (The reduction of diabetes
Finnish Diabetes Risk Score test [FINDRISK]). through DEHKO has
Those at high risk are encouraged to have a led to the development
health check-up in primary care which includes of a much broader
an offer of education and support to reduce risk approach of reducing
either with individual sessions or in groups. risk of chronic non
o A strategy of early detection and management communicable
 Improving quality of care of people with type 2 diabetes diseases with ‘One Life’
with a focus on reducing the risk of cardiovascular
disease  For those people who
 Supporting self-care of people with type 2 diabetes received the
intervention, there was
In addition ‘One Life’ focusses on: a small reduction in the
number of CVD events
 Raising awareness of cardio-vascular health amongst expected over the next
the general population 10 years
 Improving the health outcomes of patients with
cardiovascular disease through education and
improved access to care

This case study focuses on the DEHKO risk factor prevention
strategy, the high risk population strategy and the more recent 
‘One life’ initiative, which are the parts of the programme most
applicable to a CVD prevention initiative in the UK. 

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TARGET POPULATION
Of people who attended the health check-
Whole population strategy aims to ups and individual/group sessions, men
prevent metabolic syndrome and the risk reported:
factors for type 2 diabetes and targets the
whole population. DEHKO has supported o an increase in physical
the whole population strategy but the main activity and improved
thrust of the project is on a high risk dietary pattern (9.6%)
population strategy. o an increase in physical
activity (4.1%)
High Risk strategy aims to prevent and o an improved dietary pattern
delay the development of type 2 diabetes (39.3%)
(T2D) in individuals at high risk with a o no lifestyle changes (47.0%)
focus on close relatives of individuals with
type 2 diabetes, women with a history of Women reported:
gestational diabetes, individuals with o an increase in physical
hypertension or elevated blood glucose or activity and improved
a disturbance of fat metabolism or
dietary pattern (14.2%)
metabolic syndrome, individuals with o an increase in physical
overweight or central obesity. activity (3.8%)
o an improved dietary pattern
BENEFITS AND OUTCOMES (39.2%)
o no lifestyle changes (42.7%)
One element of DEHKO was the FIN-D2D
project conducted in 2003–2008 supporting
the implementation of the prevention of
T2D in five hospital districts (about 400 PROGRAMME EXPERIENCES
health care centres/occupational health
care clinics) in Finland with existing The focus on risk reduction of diabetes
resources. This project was evaluated and through DEHKO has led to the
showed: development of a much broader approach
 In the FIN-D2D area 25% of men of reducing risk of chronic non
and 48% of women were aware of communicable diseases with ‘One Life’.
the programme compared to a The high risk population strategy in the
control area, where the proportions FIN-D2D study may be useful and
were 20% and 36% respectively applicable to primary health care settings
 Over a 12 month period of the high when it comes to prevention strategies of
risk population intervention, those T2D and CVD. However, researchers
men and women who reported concluded that commitment to lifestyle
changing their physical activity and changes in primary health care was rather
diet had a decrease in estimated low, which is why increased motivation and
10-year risk for CVD events by self-management of people at risk should
3.5% in men and 1.5% in women be emphasised.
compared to an increase of 0.15%
in men (p<0.001, between groups)
and decrease of 0.43% (p=0.027,
between groups) in women who did
not make the changes
 There was no change in estimated
mortality in individuals at high-risk
of T2D

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THE DETAIL
Context
The Finnish Diabetes Prevention Study (DPS) was one of the first RCTs showing the effect
of relatively modest lifestyle changes to prevent type 2 diabetes. Based on results of DPS, a
nationwide programme for the prevention of type 2 diabetes, DEHKO was launched in
Finland as part of the Finnish National Diabetes Programme. This was established as a ten
year programme and ran from 2000 to 2010.

DEHKO aimed to prevent type 2 diabetes and diabetes related complications and conditions;
to improve the quality of diabetes care and to support the self-care of people with diabetes.
DEHKO has supported the whole population strategy, but the main thrust of the project is on
a high risk population strategy.

From the outset of the programme, diabetes was treated as a serious cardiovascular risk
factor; “The second most important task is to agree upon measures to reduce the risk of
CVD among people with type 2 diabetes – requiring a substantial change of attitude by the
decision makers in the healthcare field and the care providers. The central message is that
type 2 diabetes is by no means a “mild diabetic disease” but a fatal cardiovascular disease if
all the risk factors are not properly treated.” (Development Programme for the Prevention
and Care of Diabetes in Finland, 2000-2010’, Tampere 2001).

The DEHKO programme was co-ordinated by the Finnish Diabetes Association, working with
primary health care, specialised medical care, occupational health care, and the National
Public Health Institute. It included FIN-D2D, a special programme for the prevention of type
2 diabetes.

From 2011, the DEHKO programme became ‘One Life’, which encompassed the Finnish
Diabetes Association, Finnish Brain Association and the Finnish Heart Association. The
programme was aimed at raising awareness in the whole population about all risk factors for
common non communicable diseases including CVD, dementia, COPD and diabetes, with a
focus on prevention, health promotion and seeing the person as a whole.

Goals, Values and Principles

 Prevention of type 2 diabetes through:
o A whole population strategy of awareness raising
o A high risk population strategy
o A strategy of early detection and management
 Improving quality of care of people with type 2 diabetes with a focus on reducing the risk
of cardiovascular disease
 Supporting self-care of people with type 2 diabetes

In addition ‘One Life’ focusses on:

 Raising awareness of cardiovascular health amongst the general population
 Improving the health outcomes of patients with cardiovascular disease through education
and improved access to care

Population
Current figures according to the Finnish Diabetes Association website (March 2018) are that
Finland has a population of 5.5 million. They estimate that there are 50,000 people with type
1 diabetes and about 300,000 people with type 2 diabetes in Finland. About 4,000 children
under the age of 15 have diabetes. The number of undiagnosed cases of type 2 diabetes is
estimated at 150,000. Approximately 10% of the population has diabetes.

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Two strands of the DEHKO strategy targeting different groups are

 Whole population strategy aims to prevent metabolic syndrome and the risk factors for
type 2 diabetes and targets the whole population DEHKO has supported the whole
population strategy but the main thrust of the project is on a high risk population strategy.
 High Risk population strategy aims to prevent and delay the development of type 2
diabetes in individuals at high risk with a focus on close relatives of individuals with type
2 diabetes, women with a history of gestational diabetes, individuals with hypertension or
elevated blood glucose or a disturbance of fat metabolism or metabolic syndrome,
individuals with overweight or central obesity

‘One Life’ incorporates both the whole population strategy and high risk population strategy
for those at high risk of CVD, type 2 diabetes, COPD and dementia.

Service Delivery
Whole population strategy
One of the programme goals was to raise awareness of diabetes and its risk factors in the
whole population through various activities such as media campaigns and health fairs. No
further information was available on how awareness raising through these routes was
achieved.

High risk strategy

The general target of the FIN-D2D program conducted in 2003–2008 was to support
implementation of the prevention of T2D in five hospital districts (about 400 health care
centres/occupational health care clinics) in Finland with existing resources.

 There was a population wide promotion of screening using the modified Finnish Diabetes
Risk Score test (FINDRISC) which can be completed through health care units,
pharmacies, the internet and public campaign events.
 People eligible for the intervention were those who scored ≥15 points in the FINDRISC
or had a history of ischemic cardiovascular events, gestational diabetes, impaired fasting
glycaemia (IFG) or impaired glucose tolerance (IGT). They were offered support to
reduce their future T2D risk. The initial intervention was an in depth health check-up.
 Health check-ups included:
o in depth questionnaires about life style (tobaccos smoking, physical activity, diet)
o an oral glucose tolerance test
o a test for levels of total and high density lipoprotein cholesterol
o a measurement of systolic and diastolic blood pressure (mm Hg)
o use of antihypertensive medication, verified from prescriptions if possible
 Framingham Risk Score (FRS) was calculated for those ≥30 years and for those ≥45 the
10 year CVD mortality risk (Systematic Coronary Risk Evaluation (SCORE) was
calculated.
 Participants were offered the opportunity to participate in individual or group-based
lifestyle counselling in primary health care setting conducted by local nurses. The goal
was to encourage them to change their lifestyle in the recommended direction and
recognise risk factors in their own lifestyle.
 The topics of the individual counselling sessions were based on needs, and the focus
was on physical activity, meal frequency, alcohol, fat and fibre intake, salt use, weight
and smoking.
 The group sessions included weight maintenance and exercise groups and lectures on
diabetes and lifestyle changes.
 Staff were given training for the purpose and for the practical implementation of the
program. The programme was promoted in healthcare units which referred people into
the programme.

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The One Life programme:

One Life, established in 2011 after DEHKO ended, has been established on many of the
same principles as DEHKO, with some developments. The programme has not been
formally evaluated but discussion with a Project Manager at One Life provided some
overview of aims and achievements:

 People have said that they lack money and time for their health, so there is an effort to
show that this need not be an obstacle. One Life provides concrete aids to support small
decisions that people make about their health every day e.g. small cards to deliver in
seminars where people are sitting for a long time, reminding them to spread their feet,
move around in their chair
 One Life organise a Health for All day, which includes a ‘dream day of exercise’, usually
10th May, which might include going to the gym, hiking, climbing etc. Around 2,000
people are thought to have organised an event that day
 Workplaces are engaged, and currently 800 workplaces receive a newsletter every
Monday morning outlining exercises and ideas for health. People who attend the
workplace activity are sent further information about how to improve their health
 ‘Dream Day of work’ is normally held on 5th October and encourages workplaces to
promote workers’ health. Activities include webinars, sharing a healthy breakfast
together, exercise tasters, competitions, etc.

Where the general public has been targeted, the focus has been on people at risk or who
already have diabetes, heart disease or a brain related illness:

 Gestational diabetes courses are run for pregnant women. This is a free 3 week web-
based course on health, diet, exercise and relaxing. The course runs monthly and there
are 50-60 attendees on the course at a time
 There is a three week web-based course for women who have previously had
gestational diabetes. The course runs every second month, and is very popular, with
around 250 people on the course at a time
 For people newly diagnosed with type 2 diabetes there is a nurse-run web-based course.
The course is available to 30 people at a time, and they are able to discuss lifestyle, diet
and exercise.
 The web courses were viewed by One Life as one of the most effective interventions.
The courses are of good quality, engagement is high and feedback has been positive
 Campaigns in the community have included targeting high blood pressure. Events
where people can have their blood pressure measured have been popular. In 2017,
100,000 people had their blood pressure measured during a one week campaign
 Finnish television is required to offer public health associations some time slots for free,
which One Life has used.

The intention is to give people realistic and achievable goals. Social media has been a good
way to share conversations and experiences.

Healthcare providers and policy makers:

 Some interventions are targeted at healthcare providers. They are often given ‘stories’,
by patients, of what it is like to live daily life with diabetes or heart disease and how those
people might wish to be treated. Small workshops are delivered and tools provided
 Dialogue with decision makers is key. They are supportive, but financial considerations
are very important. They understand that prevention is cheaper and One Life provide
examples and evidence to demonstrate this at both regional and national level e.g.
around cycling in Helsinki, where 100km of cycle path has been built and One Life were
able to prove that it was cheaper to build those than to deal with illness.

International CVD Prevention Case Study Report Page | 73

 One Life are hoping for policies to be put in place to sustain the changes they have seen,
and to some degree this has been achieved. For example, there has been a greater
focus in Finland on children’s health, and national decision makers have attributed this in
part to One Life
 Working together is seen as key to success

More recently, in addition to heart, brain and diabetes, the work of One Life has also
incorporated respiratory health and mental health, as many of the risk factors and solutions
are shared. One Life continues the work of the DEHKO diabetes programme in the
prevention and care of diabetes. There is a stated effort to further work to make
rehabilitation and peer support an integral part of care and there are sub-projects that stress
the pursuit of:

 Rehabilitation and peer support as part of the care of type 1 and type 2 diabetes,
bringing vascular risks under control and promoting lifelong vascular health
 Gaining control over diabetes expertise by ensuring versatile health communications and
awareness raising and producing measures with tools, training publications and
guidelines

Outcomes
Whole Population strategy
A study carried out a survey of people to understand if DEHKO had any impact of raising
awareness and self-reported lifestyle changes in Finnish middle-aged population. (Wilkstrom
et al 2015).

‘Health Behaviour and Health among the Finnish Adult Population’ is a postal survey
conducted annually by the National Institute for Health and Welfare. To facilitate the
evaluation of the FIN-D2D, questions regarding diabetes prevention programme and self-
reported changes in health habits were included into the survey in the years 2004-2008.
Based on these questions, it was possible to assess the change in public awareness of
diabetes prevention and T2D risk factors over the lifespan of the FIN-D2D project. The
participants aged over 35 years were included in this analysis. The dataset included 5,007
men and 5,975 women. After excluding participants with missing data on awareness of
diabetes prevention programme (n=151), the final dataset included 10,831 men and women.

Results from this survey showed that:

 In the FIN-D2D area 25% (347/1384) of men and 48% (797/1674) of women reported
being aware of the programme
 In the control area, the proportions were 20% (702/3,551) and 36% (1,514/4,222),
respectively
 The overall awareness increased among both genders and in all areas during the project
period, but the level of awareness was consistently higher in the FIN-D2D area
 Female gender and higher age were associated with increasing awareness of the
programme in both areas
 Self-reported lifestyle changes were more common among women, but associated with
the level of awareness of the programme more often among men than women

Researchers concluded that the awareness of diabetes and its risk factors increased among
men and women in both implementation and control areas during the FIN-D2D project
period. The activities of the implementation project may at least partly explain the
differences in lifestyle changes between areas, especially among men. The results suggest
that health promotion campaigns increase the population awareness about the prevention of
chronic diseases and as a result, especially men may be prompted to make beneficial
lifestyle changes.

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High risk strategy
A study carried out by Rautio et al (2015) showed the impact of the strategy to detect people
at high risk of developing diabetes and the impact on CVD risk reduction of the intervention
they were offered to support them to change their lifestyle.

Table 1 presents the mean baseline estimated 10 year risk for CVD events and mortality
estimated by risk-calculators. During the one-year follow up the FRS decreased in women
and the SCORE decreased in men.

During the one-year follow-up:

 9.6% of the 1052 men reported both an increase in physical activity and improved dietary
pattern
 4.1% of 1052 men reported an increase in physical activity
 39.3% of 1049 men reported an improved dietary pattern
 47.0% reported no lifestyle changes
 14.2% of the 1995 women reported both an increase in physical activity and improved
dietary pattern
 3.8% of the 1995 women reported an increase in physical activity
 39.2% of 1995 women reported an improved dietary pattern
 42.7% reported no lifestyle changes

The estimated 10-year risk for CVD events decreased 3.5% in men and 1.5% in women
reporting an increase in physical activity and improvement in diet, compared to an increase
of 0.15% in men (p<0.001, between groups) and decrease of 0.43% (p=0.027, between
groups) in women with no lifestyle changes after adjustment for age and baseline
Framingham Risk Score.

Numbers needed to treat to prevent one CVD event by lifestyle changes were 25 for men
and 59 for women.

Researchers concluded that lifestyle counselling offered in primary health care for one year
resulted in beneficial changes in dietary pattern and physical activity, which were associated
with a reduction in the estimated 10-year CVD event risk, but not with reduction in estimated

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mortality in high-risk individuals for T2D. It was felt that this kind of effort may be useful and
applicable to primary health care settings when it comes to prevention strategies for T2D
and CVD. Researchers felt that commitment to lifestyle changes in primary health care was
rather low, which is why increased motivation and self-management of people at risk should
be emphasised.

Separate analysis was carried out of the impact of the intervention on women with
gestational diabetes (GDM) (Riatio et al 2014).

 Altogether 1,661 women aged ≤ 45 years participated in the programme. One-year

follow-up was available for 393 women who did not have screen-detected T2D at
baseline, and 265 of them had at least one intervention visit [115 (43.4%) women with
history of GDM and 150 (56.6%) without history of GDM]
 At baseline, women with GDM had similar baseline glucose tolerance but better
anthropometric characteristics, blood pressure, and lipid profile than women without
GDM after adjustment for age
 Beneficial changes in cardiovascular risk profile existed among women with and without
GDM during follow-up and the effect of lifestyle intervention was similar between the
groups, except that low-density lipoprotein cholesterol improved only in women with
GDM. Altogether, 4.0% of those with GDM and 5.0% of those without GDM developed
T2D (p = 0.959 adjustment for age)
 Researchers concluded that the effect of a 1-year lifestyle intervention in primary
healthcare setting was similar regardless of history of GDM, both women with and
without GDM benefitted from participation in the lifestyle intervention

There has been no evaluation of the ‘One Life’ initiative.

Leadership and Governance

The DEHKO Coordination Committee, at the outset of the programme was chaired by a
professor from the University of Helsinki, with 16 other members on the committee who
appear to represent several working groups: Care Organisation and Resources, Diabetes
Cost, The Role of the Person with Diabetes, Education, Type 2 Diabetes, Prevention of Type
2 Diabetes, Type 1 Diabetes, Diabetes Registries. In addition, there were Medical Directors
from two Health Care Centres, and representatives from the Finnish Diabetes Association
including the Chairperson and Vice-Chairperson, the Managing Director, Chief Physician
and Communications Manager.

‘One Life’ is a joint initiative in partnership with the Finnish Brain Association, the Finnish
Diabetes Association and the Finnish Heart Association. DEHKO has continued to focus
primarily on diabetes as the broader ‘One Life’ programme has been implemented and there
is coordination between the groups leading the programmes to ensure economies of scale
and consistent messaging.

Finances
The Finnish Government supports the DEHKO and other diabetes programmes with revenue
generated by Finland’s Slot Machine Association (RAY).

The financing for the FIN-D2D Project (2000–2007), which targeted the obese, at-risk
population and included screening and lifestyle counselling, early diagnosis, and treatment,
came from a variety of sources: RAY, the five district hospitals engaged in the project, the
Ministry of Social Affairs and Health, the National Public Health Institute, and the Finnish
Diabetes Association.

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The transition from DEHKO to One Life was considered relatively simple as financing was
available from the Slot Machine Association which funds health services and there was no
need to request funding from elsewhere.

Finland’s Slot Machine Association (Raha-automaattiyhdistys, RAY) was established in 1938

to raise funds through gaming operations to support Finnish non-profit organizations and
foundations in the areas of social welfare and health. RAY has an exclusive right in Finland
to operate slot machines, table games and casinos.

Human Resources
No information was available

Infrastructure and Supplies

See Training below

Knowledge and Information

Training
There is little detailed information about other training available to patients or to staff
specifically related to the DEHKO programme. The one year diabetes prevention
programme was established in a clinical setting in primary health care with no extra facilities
or specific longer-term education of the staff, and lifestyle counselling was implemented by
local nurses. Under the One Life programme there are a number of training courses related
to gestational diabetes and people newly diagnosed with type 2 diabetes, which may have
some basis in the studies related to these groups, but this is not explicitly stated.

The Diabetes Centre in Tampere organise a number of counselling and training courses for
people with diabetes, their family members and health care professionals and estimate that
1 600 people attend these each year.

Education and further training for health care professionals include several seminars and
basic and advanced courses. Tailor-made education and counselling are also offered for
health care professionals.

The staff responsible for courses, training and education at the Diabetes Centre includes two
physicians, four nurses, two nutritionists, one psychologist, a chiropodist, a physical activities
instructor, an exercise planner, kitchen personnel, two course secretaries, an education
manager and an education secretary.

Data collection
The Health Behaviour and Health among the Finnish Adult Population survey is an annual
postal survey conducted by the National Institute for Health and Welfare. The primary
purpose is to obtain information on the current health behaviour of the working-age
population with a self-administered questionnaire. The survey examines key aspects of
health behaviour such as food habits, physical activity, smoking and alcohol consumption
and includes questions on participants’ sociodemographic background and medical history.
To facilitate the evaluation of the FIN-D2D, questions regarding the diabetes prevention
program and self-reported health habits were included in the survey in the years 2004-2008.

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REFERENCES
 Koski S. Interview with SPH, Feb 2018
 Rautio N. Jokelainen J. Polonen A. Oksa H. Peltonen M. Vanhala M. Puolijoki H.
Moilanen L. Tuomilehto J. Uusitupa M. Keinanen-Kiukaaniemi S. Saaristo T.
Changes in lifestyle modestly reduce the estimated cardiovascular disease risk in
one-year follow-up of the Finnish diabetes prevention program (FIN-D2D). European
Journal of Cardiovascular Nursing 2015, Vol. 14(2) 145– 152
 Rautio N. Jokelainen J. Korpi-Hyovalti E. Oksa H. Saaristo T. Peltonen M.
Loilanen L. Vanhala M. Uusitupa M. Tuomilehto J. Keinanen-Kiukaaniemi S.
Lifestyle Intervention in Prevention of Type 2 Diabetes in Women With a History of
Gestational Diabetes Mellitus: One Year Results of the FIN-D2D Project. Journal of
Women’s Health, Volume 23, Number 6, 2014
 Wikstrom K. Lindstrom J. Tuomilehto J. Saaristo T E. Helakorpi S. Korpi-Hyovalti
E. Oksa H. Vanhala M. Keinanen-Kiukaanniemi S. Uusitupa M. Peltonen M.
National diabetes prevention program (DEHKO): awareness and self-reported
lifestyle changes in Finnish middle-aged population. 2015 Public Health. 2015
Mar;129(3):210-7

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Appendix 5: France ESCAPE Trial

THE ESCAPE TRIAL – a multifaceted

intervention on cardiovascular risk factors in
high-risk hypertensive patients
A CASE STUDY

PROGRAMME AT A GLANCE
ESCAPE, conducted in France from 2006 to 2008, was a
pragmatic cluster randomised controlled prevention trial. It
was designed to show whether a multifaceted intervention,
aimed at general practitioners (GPs), could significantly
increase the proportion of hypertensive patients at high risk of
cardiovascular disease (CVD) who achieved all their
recommended therapeutic targets.

GPs in the intervention group received one day of medical

education on therapeutic targets and strategies featured in KEY
the French guidelines on treatment of hypertension and TAKEAWAYS
type 2 diabetes, and were given a validated electronic blood
pressure measurement device to improve the accuracy of  Interventions that
blood pressure measurements and a leaflet that summarised target healthcare
targets and therapeutic strategies. providers and place
less emphasis on
To be included patients had to, be aged between 45 and 75 patients’ lack of
years, be treated for hypertension for at least six months, not adherence can help
have any known clinical signs or history of CVD, and have at reduce therapeutic
least two cardiovascular risk factors from a list of eight inertia (failure to start
including age, family history, smoking, type 2 diabetes, LDL or or increase treatment
HDL cholesterol levels, known left ventricular hypertrophy and when targets are not
urinary excretion of albumin. met)
Every six months during the two-year trial GPs held a  Prevention dedicated
prevention-dedicated consultation to optimise (if needed and consultations were
possible) the treatment of the patients who had not achieved effective
their individual targets. The GPs were also asked to discuss
systematically the patient’s diet, exercise and adherence to  Patients did not
drug treatment and to give advice on quitting smoking if the report an adverse
patient smoked. At baseline and one year follow-up GPs effect on their quality
received feedback on their patients’ clinical and biological of life caused by
data. Prescriptions of drugs for hypertension and metabolic more intensive
treatment were reported at baseline and 24 months. management of their
CVD risk
In France, at the time of this study, 92% of patients treated for
hypertension for prevention of CVD were followed exclusively
by GPs. This programme moved the focus from lack of
adherence by patients to reducing ‘therapeutic inertia’ by
targeting an intervention to the healthcare providers.

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TARGET POPULATION PROGRAMME EXPERIENCES
To be included patients had to, be aged The main impact of the intervention was
between 45 and 75 years, be treated for principally due to the proportion of patients
hypertension for at least six months, not achieving their blood pressure targets and
have any known clinical signs or history of the increased prescription of low -dose
CVD, and have at least two cardiovascular aspirin for patients with type 2 diabetes.
risk factors from a list of eight including Other components of the primary outcome
age, family history, smoking, type 2 measures also improved significantly within
diabetes, LDL or HDL cholesterol levels, each group, but their change over time was
known left ventricular hypertrophy and comparable between the two groups.
urinary excretion of albumin.
In the ESCAPE trial, the percentage of
patients achieving all their therapeutic
BENEFITS AND OUTCOMES targets at baseline was very low overall
(8.2%), and even lower for patients with
 This was considered to be an easy- type 2 diabetes (1.5%). This raises
to-perform multifaceted questions, not only about the quality of
intervention, targeting only GPs care provided by the GPs regarding the
 After two years, the proportion of practice guidelines, but also about the
patients achieving all their accessibility and relevance of the
therapeutic targets increased therapeutic targets recommended for
significantly in both groups, but primary care settings.
significantly more in the intervention
group It is likely that both the higher blood
pressure and the higher prescription of
 Systolic and diastolic blood low-dose aspirin seen at baseline in the
pressures decreased significantly intervention group were due to the
more in the intervention group than intervention itself. During the training
in the usual care group, by 4.8 seminar, prior to the inclusion of patients,
mmHg and 1.9 mmHg, respectively. GPs were given an electronic
The authors suggest that the measurement device and were asked to
absolute difference in the reduction report the exact values on the case report
of SBP of about 5mmHg in the forms, which almost certainly improved the
intervention group was clinically accuracy of their BP measurements by
relevant because this difference reducing substantially end-digit preference.
could be expected to reduce stroke The BP was shown to be underestimated
mortality by 20%, and mortality in the usual care group because of a much
related to cardiac ischaemic events higher end-digit preference. The report
or long-term overall cardiovascular suggests that GPs involved in the trial
mortality by 15% tended to round down BP results to the
 There were no significant lower 0 mmHg or 5 mmHg values
differences in changes in physical systematically because it is considered
and mental quality of life between better for the physician, as well as for the
groups. This suggests that there patient, to have a lower value under
was no ‘price to pay’ for a more treatment.
intensive management to reduce
cardiovascular risk in terms of GPs recruited to take part all belonged to
quality of life the French National College of Teachers in
General Practice and so they may be more
motivated than those who were not GP
trainers to apply themselves to the
programme.

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THE DETAIL
Context
Several observational studies on hypertensive patients have shown a gap between
therapeutic targets recommended in guidelines and those achieved in daily practice. The
ESCAPE trial aimed to determine whether a multifaceted intervention focused on general
practitioners (GPs), could increase significantly the proportion of hypertensive patients at
high risk of cardiovascular disease (CVD) who achieved all their recommended therapeutic
targets.

Goals, Values and Principles

French and European guidelines for the prevention of cardiovascular complications in
patients with hypertension are mainly based on blood pressure (BP) targets that should be
achieved along with other risk reducing strategies. As these patients are at an increased
cardiovascular risk, the recommendations also set targets for low-density lipoprotein
cholesterol (LDL), smoking cessation, and, in patients with type 2 diabetes, HbA1c and low-
dose aspirin treatment.

The primary endpoint for this programme was the change in the proportion of patients
achieving all of their therapeutic targets at two years.

Three therapeutic targets were defined for patients without type 2 diabetes: BP ≤ 140/90
mmHg, LDL ≤ 3.36 mmol/l, and no smoking.

Five therapeutic targets were defined for patients with type 2 diabetes: BP ≤ 130/80 mmHg,
LDL ≤ 2.59 mmol/l, HbA1c ≤ 7%, no smoking, and a prescription for low-dose aspirin.

Key secondary endpoints were the change in the proportion of patients achieving each of
their individual targets and the values for BP, LDL, and HbA1c.

Other secondary endpoints were the variation in the Framingham-Anderson score for
coronary risk, the occurrence of the first clinical cardiovascular event (validated by a
committee blinded to randomization), change in antihypertensive drug prescriptions, and
quality of life.

There was an intention to address the ‘diagnosis and treatment gap’ by targeting health
providers and moving the focus from lack of patients’ adherence.

The approach was pragmatic using existing resources and guidance but requiring more
consultation and, potentially, prescription/ treatment.

Population
This was a national programme, involving 257 GPs in clusters randomised by region, from
23 colleges that were all members of the French National College of Teachers in General
Practice (CNGE).

A total of 905 patients received the intervention, and 927 received usual care: analysis at
primary endpoint was 860 for usual care group and 860 for intervention.

Patients’ inclusion criteria

To be included patients had to, be aged between 45 and 75 years, be treated for
hypertension for at least six months, not have any known clinical signs or history of
cardiovascular disease, and have at least two of the following cardiovascular risk factors:

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 Age ≥ 50 years for men and ≥ 60 years for women
 Family history of myocardial infarction or sudden early death (at ≤ 55 years for a first-
degree male relative or ≤ 65 years for a first-degree female relative) or stroke at ≤ 45
years for a first-degree relative
 Active smoker or having quit smoking < three years ago
 Treated or untreated type 2 diabetes (fasting hyperglycaemia ≥ 7 mmol/L at two
occurrences or use of an anti-diabetic drug)
 LDL ≥ 4.14 mmol/L or use of lipid-lowering drug
 High-density lipoprotein cholesterol (HDL) ≤ 1.04 mmol/L (one risk factor was subtracted
if HDL ≥ 1.55 mmol/L)
 Known left ventricular hypertrophy (diagnosed by ultrasound or electrocardiography)
 Urinary excretion of albumin ≥ 20 mg/L

GPs were asked to include the first eligible patients they saw over a week, with a minimum
of seven patients.

Exclusion criteria:
Patients were not eligible if:

 They had type 1 diabetes

 Were unable to participate in a two-year trial
 Had a serious life-threatening disease with a poor short-term prognosis
 Or could not understand French

Recruitment of GPs:
 Eleven colleges (173 GPs) were randomised to the usual care group and 12 (162 GPs)
to the intervention group
 Attendance at the one-day training in the intervention group or the 90 minute-meeting in
the usual care group was mandatory for GPs to include patients
 145 GPs (90%) in the intervention group attended the one-day training, of which 126
(87%) recruited at least one patient in the trial
 144 GPs (83%) in the usual care group attended the 90 minute-meeting, of which 131
(90%) included at least one patient
 The characteristics of the active GPs were similar in both groups in terms of gender, age,
type and duration of practice
 The mean number of patients recruited per GP was 7.1 (minimum = 1, maximum = 16)

Recruitment of patients:
 Between November 2006 and July 2007 1,832 patients were included in the trial, 927 in
the usual care group and 905 in the intervention group
 On average they were 62 (standard deviation (SD) 7.8) years old, and the sex ratio of
men to women was 2:1. All patients were receiving treatment for prevention of CVD, had
been treated for hypertension for an average of 10.9 years (SD 8.1), and 71% had more
than two other cardiovascular risk factors associated with hypertension. The average
body mass index was 30.5 kg/m2. The average diabetes duration of the 1,047 patients
with type 2 diabetes was 7.5 years (SD 6.5)
 At baseline patient characteristics were comparable in both groups, except for systolic
BP (SBP) and diastolic BP (DBP), which were significantly higher in the intervention

International CVD Prevention Case Study Report Page | 82

 group by 7 mmHg and 3 mmHg respectively (p < 0.001). In addition, significantly fewer
diabetic patients had a prescription for aspirin in the usual care group compared with the
intervention group: 26.9% versus 42.7% (p < 0.001). Finally, the percentage of patients
achieving all of their therapeutic targets at baseline was significantly lower in the
intervention group: 6.2% versus 10.2% (p = 0.005)

Service Delivery
The programme ran for a two year fixed period from 2006 to 2008.

The intervention consisted of:

 One day of medical education for GPs, including some focus on the therapeutic targets
and strategies for achievement, featured in the French guidelines on hypertensive and
type 2 diabetes (T2D) patients' care
 An electronic blood pressure (BP) measurement device for GPs
 A leaflet for GPs summarising the guidelines
 Four prevention dedicated consultations for each patients twice a year, performed by the
GP. During these, the GP was to negotiate drug changes if guidelines targets were not
achieved, and systematically assess patient's compliance, dietetics, exercise, and
smoking issues if needed
 Feedback for GPs on patients' results at baseline and at 1 year follow-up

Outcomes
The programme was evaluated by a pragmatic cluster randomised trial comparing
intervention (n=905), GPs having attended training, offering patients 6 monthly consultations
focused on optimizing treatment and discussing lifestyle, versus usual care (n=927). A total
of 1,832 high-risk (of CVD) hypertensive patients were included.

The primary endpoint for this programme was the change in the proportion of patients
achieving all of their therapeutic targets at two years.

Three therapeutic targets were defined for patients without type 2 diabetes: BP ≤ 140/90
mmHg, LDL ≤ 3.36 mmol/l, and no smoking.

Five therapeutic targets were defined for patients with type 2 diabetes: BP ≤ 130/80 mmHg,
LDL ≤ 2.59 mmol/l, HbA1c ≤ 7%, no smoking, and a prescription for low-dose aspirin.

Key secondary endpoints were the change in the proportion of patients achieving each of
their individual targets and the values for BP, LDL, and HbA1c.

Other secondary endpoints were the variation in the Framingham-Anderson score for
coronary risk, the occurrence of the first clinical cardiovascular event (validated by a
committee blinded to randomisation), change in antihypertensive drug prescriptions, and
quality of life.

Key results:
 After two years the proportion of patients achieving all their therapeutic targets increased
significantly in both groups, but significantly more in the intervention group: Between
group OR (odds-ratio) 1.89, (95% confidence interval (CI) 1.09 to 3.27, p = 0.02)
 Significantly more patients achieved their blood pressure targets in the intervention
group than in the usual care group: OR 2.03 (95% CI 1.44 to 2.88, p < 0.0001)

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 Systolic and diastolic blood pressures decreased significantly more in the intervention
group than in the usual care group, by 4.8 mmHg and 1.9 mmHg, respectively (p <
0.0001 for both SBP and DBP)
 There were no significant difference in changes in physical and mental quality of life
between groups
 At baseline patient characteristics were comparable in both groups, except for SBP and
DBP, which were significantly higher in the intervention group by 7mmHg and 3 mmHg,
respectively (p < 0.001)
 In addition significantly fewer diabetic patients had a prescription for aspirin in the usual
care group compared with the intervention group at baseline: 26.9% versus 42.7% (p
<0.001)
 The percentage of patients achieving all of their therapeutic targets at baseline was
significantly lower in the intervention group: 6.2% versus 10.2% (p = 0.005)

Primary endpoint
Due to missing values at every time point, the primary endpoint could not be modelled for six
patients; therefore, the analysis for the primary endpoint was based on 1,826 patients. Over
two years of follow-up, the proportion of patients achieving all of their therapeutic targets
increased in both groups, but the increase was significantly higher in the intervention group:
OR 1.89, 95% CI 1.09 to 3.27, p = 0.024 (Table 1). Similar trends were observed in patients
with and without type 2 diabetes, but did not achieve statistical significance.

Table 1 Primary outcome: changes within groups and differences between groups at
month 24 (M24) in the proportion of patients achieving all their therapeutic targets
Endpoint Group M0 n/N (%) M24 n/N (%) OR (95% CI) P OR (95% CI) P-
for within for between value
group group
All patients 3 Intervention 56/900(6.2) 110/860(12.8) comparison
3.23(2.12 to <0.001 comparison
1.89(1.09 to 0.024
or 5 targets 4.94) 3.27)

Usual care 94/923(10.2) 118/860(13.7) 171(1.19 0.004

to2.47)

Hypertension Intervention 7/527 (1.3) 24/526 (4.6) 3.90 (1.60 to 0.003 2.36 (0.68 to 0.175
+ T2D (5 0.52) 8.18)
targets)
Usual care 9/520 (1.7) 14/513 (2.7) 1.65 (0.69 to 0.262
3.98)

Hypertension Intervention 49/373 86/334 (25.8) 3.12 (1.94 to <0.001 1.63 (0.99 to 0.120
(3 targets) (13.1) 5.03) 3.01)

Usual care 85/403 104/347 1.91 (1.27 to 0.002

(21.1) (29.0) 2.88)
CI, confidence interval; MO, month 0 or baseline; M24, month 24; T2D, type 2 diabetes; OR, odds ratio

Secondary endpoints
Individual therapeutic targets
The proportion of patients achieving their BP targets did not change significantly in the usual
care group. However, significantly more patients in the intervention group achieved their BP
targets at two years. The difference between the two groups was significant: OR 2.03, 95%
CI 1.44 to 2.88, p < 0.001 (Table 2). The proportion of patients achieving their targets for
LDL and not smoking increased in both groups, with no significant difference between the
groups. There was no change in the proportion of patients with HbA1c ≤ 7% in either group
in the type 2 diabetes sub-population.

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Table 2 Within group and between group differences in the percentages of patients
achieving their individual therapeutic targets
Target Group M0 n/N M24 n/N OR (95% CI) P OR (95% CI) P-
(%) (%) for within for between value
group group
comparison comparison
Blood Intervention 207/900 303/823 2.55 (1.96 to <0.001 2.03 (1.44 to <0.001
a
pressure (23.0) (36.8) 3.30) 2.88)
Usual care 392/923 382/825 1.25 (0.99 to 0.060
(42.6) (46.3) 1.58)
LDL Intervention 370/884 458/793 2.65 (2.05 to <0.001 1.25 (0.88 to 0.205
b
cholesterol (41.9) (57.8) 3.41) 1.78)
Usual care 395/910 435/778 2.11 (1.65 to <0.001
(43.4) (55.9) 2.71)
No smoking Intervention 712/905 664/804 3.75 (1.92 to <0.001 0.81 (0.41 to 0.550
(78.7) (82.6) 7.30) 1.60)
Usual care 709/926 659/808 2.98 (1.81 to <0.001
(76.6) (81.6) 4.93)
CI, confidence interval; MO, month; M24, month 24; T2D, type-2 diabetes; OR, odds-ratio
a
≤140/90mmHg or ≤130/80mmHg for type 2 diabetic patients
b
≤3.36mmol/l or 2.59 mmol/ for type 2 diabetic patients
c
≤7%

Other endpoints
 SBP was reduced by 1.2 mmHg in the usual care group and by 6.0 mmHg in the
intervention group. The 4.8 mmHg difference between the two groups was statistically
significant, in favour of the intervention group (p < 0.001). Similarly, for DBP, the
difference between the groups at the end of the trial was 1.9 mmHg, statistically
significant in favour of the intervention group (p < 0.002)
 At baseline the Framingham-Anderson scores were comparable in the two groups and
decreased by 1.2% in the usual care group and by 2.2% in the intervention group over
the 2 year period. The difference between the two groups was statistically significant in
favour of the intervention group (p < 0.001)

Sensitivity analysis of blood pressure

 Restricting the analysis to centres that measured blood pressure with an automatic
device (900 patients in the intervention group and 248 in the usual care group) gave
similar results, with a significant difference in favour of the intervention group for the
change in systolic (3.5 mmHg, p = 0.001) and diastolic blood pressure (1.3 mmHg, P =
0.045) over the 2 year period of the trial

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Analysis of changes in blood pressure adjusted on baseline values
 Blood pressure data was analysed with an adjustment on baseline values to assess the
extent to which the differential changes observed during follow-up were independent of
the between-groups difference at baseline. The results still demonstrate a significant
effect of the intervention. For SBP, time effect was significant (p =0.018) and the
intervention effect (p < 0.0001) and the interaction between group and time were also
significant (p < 0.0001). The adjusted difference over two years of follow-up was 4.8
mmHg. For DBP, time effect was significant (p = 0.0003) and the intervention effect (p <
0.0001) and the interaction between group and time were also significant (p < 0.0001).
The adjusted difference over two years of follow-up was 1.9 mmHg

Antihypertensive drugs
 At baseline the average number of antihypertensive drugs per patient was similar in the
two groups, 2.16 (SD 1.04) in the intervention group and 2.18 (SD 1.04) in the usual care
group. After two years, this number increased in both groups but increased significantly
more in the intervention group: 2.41 (SD 1.05) versus 2.29 (SD 1.06) in the usual care
group, (p = 0.020). In addition, significantly more patients in the intervention group
received at least one additional antihypertensive drug over the two-year study period
than in the usual care group (p = 0.009)

Cardiovascular events
 During the study 89 cardiovascular events were reported, and 61 were validated using
patient records by a committee blind to randomization. The incidence of the first
cardiovascular event was 3.0% in the intervention and 3.7% in the usual care groups, (p
= 0.513)

Quality of life
 Changes in scores for physical and mental quality of life were very small and not
significantly different between the two groups

Leadership and Governance

Leadership and governance was provided by the lead researchers, trial protocols and the
colleges providing the training materials for the one day training session.

Finances
The study was funded by unrestricted research grants from the French National College of
Teachers in General Practice, Takeda France, and Merck-Serono, France.

Human Resources
The physicians were all GPs and were members of the French National College of Teachers
in General Practice (CNGE). Firstly, all the 33 French regional colleges belonging to the
CNGE were invited to participate in ‘a randomized trial with hypertensive patients’. Twenty
three of these colleges agreed to participate. Eight hundred and seventy-seven GPs,
members of these 23 colleges, were contacted by each regional research leader by
telephone and/or Email, or during a usual meeting, and 335 agreed to participate.

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Infrastructure and Supplies
The study used current infrastructure and supplies. Training sessions and supplies were
held as a normal part of the GP training programme.

Knowledge and Information

Training
 A one day training session for GPs was delivered by four trained university GP lecturers
using a common teaching kit
 GPs were given blood pressure measurement device and a leaflet that summarized
targets and therapeutic strategies recommended in the guidelines which they were
asked to keep on their office desk
 As part of the trial, GPs randomised to the usual care group attended a 90 minute
meeting to learn about the inclusion and exclusion criteria and how to complete the study
case report forms

Data
 Outcomes were collated locally by GP:
o At baseline, and every six months for two years along with usual follow-up, the GPs
in both groups collected patients’ clinical and biological data
o Prescriptions of drugs for hypertension and metabolic treatment were reported at
baseline and 24 months
 Questionnaires were given by GP to patient, and responses sent directly to ‘data
treatment centre’: At inclusion, 12-months and 24-months, patients of both groups were
given a sealed envelope containing five short questionnaires on quality of life (SF-8),
adherence, diet, exercise, and smoking habits to be completed at home and sent directly
to the data treatment centre in a pre-paid envelope

REFERENCES
 Pouchain et al.: Effects of a multifaceted intervention on cardiovascular risk factors in
high-risk hypertensive patients: the ESCAPE trial, a pragmatic cluster randomised
trial in general practice. Trials 2013 14:318.

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Appendix 6: Netherlands Vascular Risk

VASCULAR RISK MANAGEMENT

management

PROGRAMME IN THE NETHERLANDS

A CASE STUDY
PROGRAMME AT A GLANCE
The programme, based in the Netherlands, assessed the
effectiveness of adding internet-based, nurse-led vascular
risk factor management to usual care for patients with
clinically manifest vascular disease. Eligible patients,
recruited between 2008-2010, had a recent clinical
manifestation of a vascular disease and a number of risk
factors that were not at the recommended levels.

Key elements of delivery for patients in the intervention

group included: KEY TAKEAWAYS
 A personalised website detailing the patient’s risk
factors that required additional treatment.  Patients that had
 A separate internet page for each risk factor with a experienced a recent
history of risk factor measurements, drug use, clinical manifestation of
treatment goal, advice from the nurse, vascular disease were
correspondence between nurse and patient and often concerned about
news items for that particular risk factor mortality and more
 Patients were asked to log in fortnightly to submit likely to take the
new measurements (blood pressure, weight, smoking required action
status, cholesterol) and to read and send messages
 Patients were encouraged to measure their own  CVD Specialist Nurses
blood pressure at home or ask their GP to measure who were already
their blood pressure. The nurse posted patients delivering care were
laboratory forms for blood tests to measure plasma trained in the function
lipids and glucose of the website and so
 Prescriptions for changes in drug regimen were this provided enhanced
posted to patients contact with existing
staff
Patients were asked to complete an online questionnaire
every three months to report newly diagnosed diseases and  The intervention in
hospital admissions. When a cardiovascular event was addition to usual care
suspected, medical records were retrieved and assessed. does not result in QALY
Patients were invited to a follow-up appointment at 12 gain at 1 year, but has
months. a small effect on
vascular risk factors
Treatment of vascular risk factors by nurse practitioners has and is associated with
been found to be effective, but is costly and time consuming lower costs
for patients and health care professionals. Delivery of the
programme via the internet was tested as a low cost method
of support compared to regular clinic attendance. CVD
Specialist Nurses who were already delivering care were
trained to carry out the intervention so this provided
enhanced contact compared to patients usual care.

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TARGET POPULATION  It was seen as productive for the
patient and nurse to work together
Eligible patients were aged 18 to 80 with a collaboratively to reduce risk
recent clinical manifestation of a vascular factors. Patients take responsibility
disease e.g. myocardial infarction, stroke for their health and are part of the
or peripheral arterial disease. Patients had solution. It is also an opportunity to
to have at least two of six treatable risk involve carers in cardiovascular risk
factors that were not at recommended management, rather than just
levels, related to systolic blood pressure, surgery or medication straight after
low density lipoprotein (LDL), triglycerides, the event
body mass index (BMI) diabetes and
smoking.

PROGRAMME EXPERIENCES
BENEFITS AND OUTCOMES
The ability of patients to see their results
 The relative change in Framingham online as soon as they were available was
Risk score of the intervention group a controversial step. One view was that
compared to the usual care group patients may access results without health
was not statistically significant when professional support which could be
adjusted for differences in patient distressing. In some areas there is a delay
attributes of a day or a week between request to
access results by the patient and the result
 Larger percentage differences being available to view by them to give
between groups were seen in health professionals time to check their
reaching the LDL recommended significance.
levels (18.4% 95%CI 5.9 to 30.9,
p=0.004) and quitting smoking After the programme was finished (1 year)
(7.7% 95%CI 0.4 to 14.9, p=0.038), the functionality of the website for patients
but there was no significant to retrieve their own records was
difference between groups for other incorporated in to the local health
risk factors electronic record system. During the trial
people could enter their own numbers, lab
 The cost effectiveness analysis results from the GP, or blood pressure
measured societal costs, quality- taken at home, but they cannot do that in
adjusted life-years (QALYs) and the current system.
incremental cost effectiveness. It
Other features of the programme including
concluded that the intervention in
an extended outpatient appointment to
addition to usual care does not
review risk factors and ongoing
result in QALY gain at 1 year, but
communication to review progress in
has a small effect on vascular risk
changes to modifiable risk factors have
factors and is associated with lower
been incorporated into the usual care of
costs
patients. Nurses can set up this system of
enhanced support if they think it might be
 Treating patients at the point where
effective for patients coming through the
they are likely to be concerned
CVD outpatients department after an
about mortality and may be self-
event.
motivated to take action was
considered to be effective and
lower cost

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THE DETAIL
Context
The Vascular Risk Management Programme was based in the Netherlands and assessed
the effectiveness of adding internet based, nurse-led vascular risk factor management to
usual care for patients with clinically manifest vascular disease.

Goals, Values and Principles

The aim of the programme is to assess the effectiveness of an internet based nurse led
programme for the management of vascular risk factors on vascular risk and vascular risk
factors in patients with clinically manifest vascular disease

The premise of the programme is that a large proportion of patients with a clinical
manifestation of a vascular disease are still at high residual cardiovascular risk due to not
reaching treatment targets.

Treatment of vascular risk factors by nurse practitioners has been found to be effective, but
is costly and time consuming for patients and health care professionals. Delivery of the
programme via the internet was tested as a low cost method of support compared to regular
clinic attendance.

Population
Patients were recruited from two centres in the Netherlands. 638 patients were invited to
participate and 330 were randomised.

Eligible patients were aged 18 to 80 with a recent clinical manifestation of a vascular disease
e.g. myocardial infarction, stroke or peripheral arterial disease. Patients had to have at least
two of six treatable risk factors that were not at target levels. These risk factors were:

 Systolic blood pressure >140mmHg

 Low density lipoprotein cholesterol >2.5mmHg
 Triglycerides >1.7mmol/L
 BMI > 25
 Diabetes or fasting glucose >6.1mmol/L
 Smoking

Patients also had to have access to internet at home, be able to read and write Dutch, and
be independent in daily activities. Patients with an estimated life expectancy of <2 years or a
malignant disease were excluded.

Service Delivery
Patients were recruited between October 2008 and March 2010. At the start of the
programme patients had a one hour outpatient appointment where they received information
on their risk factor levels. Participants randomised to the intervention group received
instructions about the internet programme and a username and password for their
personalised website.

Patients were asked to complete a questionnaire by internet every three months to report
newly diagnosed diseases and hospital admissions. When a cardiovascular event was
suspected, medical records were retrieved and assessed. Patients were invited to a follow-
up appointment at 12 months. The nurses conducting the follow-up measurements were
blinded to the patient’s group.

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Patients randomised to the intervention received an internet based programme of vascular
risk management on top of usual care. This involved:

 A personalised website focusing on the patient’s risk factors that required additional
treatment. This included an overview of the status of all risk factors (green=at goal;
yellow=close to goal; red=needs attention) and drug use
 A separate internet page for each risk factor with a history of risk factor measurements,
drug use, treatment goal, advice from the nurse, correspondence between the nurse and
patient and news items for that particular risk factor
 Patients were asked to log in at least every other week to submit new measurements
(blood pressure, weight, smoking status, cholesterol) and to read and send messages
 Patients were encouraged to measure their own blood pressure at home or ask their
general practitioner to measure their blood pressure. The nurse posted patients
laboratory forms for blood tests to measure plasma lipids and glucose
 Prescriptions for changes in drug regimen were posted to patients
 Patients were sent a summary of a news item by email every other week, to prompt the
patients to visit their website
 The internet programme was provided in addition to usual care provided by the treating
hospital physician and the general practitioner

Usual care was provided by the treating hospital physician and the general practitioner and
was based on the 2006 Dutch cardiovascular risk management guideline. The physician and
general practitioner were informed of the patient’s risk factor status.

Outcomes
Randomised controlled trial (RCT)
The programme was evaluated by a multicentre prospective RCT comparing intervention via
the internet in addition to usual care (n=155) versus usual care alone (n=159) (Vernooij et al
2012). The mean (standard deviation (SD)) age was 59.9 (8.4) and 75% were male. 16 (5%)
patients dropped out during the study and did not have follow-up measurements.

Key results:
 The relative change in Framingham risk score of the intervention group compared to the
usual care group was statistically significant at -14% (95%CI -25% to -2%)
 Adjusted for differences in the baseline score, the relative change in Framingham risk
score of the intervention group compared to the usual care group was not statistically
significant at -8% (95%CI -18% to 2%)
 The difference between groups in patients reaching the low density lipoprotein goal was
18.4% (95%CI 5.9% to 30.9%, p=0.004)
 The difference between groups in change in patients who quit smoking at 12 months
was 7.7% (95%CI 0.4 to 14.9, p=0.038)
 There was no significant difference between groups for other risk factors

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Table 1: Proportion of patients achieving risk factor targets (Veroonij et al, 2012)
Intervention Usual care
Baseline 12-months Baseline 12-months
Mean (SD) number of risk 2.9 (1.2) 3.4 (1.2) 3.1 (1.2) 3.3 (1.2)
factors on target
Systolic blood pressure 48% 54% 50% 54%
<140mmHg
LDL cholesterol <2.5mmol/L 39% 65% 41% 48%
HDL cholesterol women ≥1.3; 60% 66% 69% 72%
men ≥1.0mmol/L
Triglycerides <1.7mmol/L 55% 68% 64% 71%
Fasting glucose <6.1mmol/L 55% 52% 55% 58%
BMI <25.0kg/m2 16% 17% 26% 23%
Waist women <88; men <102cm 45% 42% 53% 44%
No smoking 73% 78% 74% 72%
Platelet aggregation inhibitor 94% 98% 97% 97%
drug
Lipid lowering drug 86% 90% 86% 88%
Blood pressure lowering drug 79% 80% 69% 75%
SD, Standard deviation, LDL, low density lipoprotein, HDL, High density lipoprotein, BMI, Body Mass Index

Forty patients reported a total of 50 vascular events (vascular interventions, stroke,

myocardial infarction, vascular mortality) and 38 patients reported 47 other severe adverse
events (death, life threatening events requiring at least one night of hospital stay or
prolonging of hospital stay, events causing significant invalidity or labour incapacity)

 Intervention group: 16 patients had 18 vascular events

 Usual care group: 24 patients had 32 vascular events
 Intervention group: 22 patients had 26 other severe adverse events
 Usual care group: 16 patients had 21 other severe adverse events

Hazard ratio for vascular events 0.66 (95%CI 0.35 to 1.24) (not statistically significant)

 152 of 155 patients in the intervention group logged in to the website with a median of 56
(interquartile range 35 to 83) logins during the year
 131 patients entered a median of 7 (3 to 14) measurements during the year, mostly
blood pressure and weight
 The monthly number of logins reduced during the 12 months from a maximum of 1,099
logins in month three to 435 logins in month 12
 134 patients sent a median of 14 (7 to 22) messages
 Patients using the website more often tended to have the highest Framingham scores at
baseline (highest CVD risk) and had the largest improvements
 During the 12 month period the nurse practitioner used a mean (SD) time of 23 (12)
minutes per month per patient

Measures
The Framingham heart risk score represents the 10 year risk for coronary heart disease. A
10% change was considered to be the minimal clinically relevant difference.

Cost-effectiveness analysis (Greving et al 2015)

The cost-effectiveness analysis used the data from the RCT

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Key findings:

 At a threshold value of €20,000 for each QALY gained, there is a 65% probability that
nurse-led, internet-based intervention is cost-effective
 No significant difference was found in health benefit in terms of QALYs (mean 0.86 for
the intervention group vs 0.85 for usual care)

Table 2: Cumulative mean costs (in €) for patients during the 12 month programme
(Greving et al 2015)
Intervention Usual care Difference
Medical costs:
GP consultation 151 142 +9
Complementary medicine 13 6 +7
practitioner consultation
Paramedic healthcare 192 294 -102
professional consultation
Specialist consultation 353 333 +20
University hospital inpatient days 249 935 -685
General hospital inpatient days 421 462 -41
Medication 451 464 -13
Internet-based vascular 220 0 +220
management programme
Subtotal medical costs 2,052 2,635 -583
Indirect non-medical costs:
Absence from paid work 2,289 1,675 +614
Reduced productivity at paid work 326 566 -240
Absence from unpaid work 159 164 -4
Subtotal indirect non-medical 2,775 2,405 +370
costs
Total costs 4,859 5,078 -219

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Table 3: Change in number of health professional visits between intervention and
usual care (Greving et al 2015)
Intervention Usual care Difference
GP visits 1 1 0
Complementary medicine 0 0 0
practitioner visits
Paramedic healthcare 3 4 -1
professional visits
Specialist visits 22 20 +2
Inpatient hospital visits 6 12 -6
Total number visits 32 38 -6

Leadership and Governance

The SMART Study Group members were from the University Medical Center Utrecht.

The study received ethical approval from the University Medical Center Utrecht and the
Rijnstate Hospital Arnhem.

The nurse practitioners were supervised by internists.

Finances
The programme was funded by a grant from ZonMw, The Netherlands Organization for
Health Research and Development.

The cost of the 1-year internet-based vascular risk factor management programme was
€220 (2009 prices) per patient.

Human Resources
The nurse practitioner personalised the website for each patient depending on the presence
of risk factors that needed additional treatment. This took an average of 10 minutes.

The nurse practitioner could view all pages for all patients and could see an overview of the
current status and last log-in attempts and new messages sent. The treating nurse logged in
every working day and replied to messages, and sent messages to patients who were not
using the programme at least every other week. In cases of non-response the nurse
contacted patients by phone. During the 12 month period the nurse practitioner used a mean
(SD) time of 23 (12) minutes per month per patient.

A research nurse completed the follow-up appointments.

Infrastructure and Supplies

A website was constructed for the programme and tested in a pilot study. The internet
programme was linked to the University Medical Center Utrecht for general information on
risk factors and vascular disease.

At the start and end of the programme patients had a one hour outpatient appointment.
Further contact between the patient and nurse practitioner in the intervention group was
through the internet.

Knowledge and Information

Training
No training requirements were mentioned.

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Data
Patients were assessed in an outpatient clinic at a baseline and 12-month follow-up visit.
Data was also collected through a diary (recording frequency of visits to the medical
specialist, nurse practitioner, general practitioner, paramedics or complementary medicine)
and questionnaires completed at baseline, 3, 6, 9 and 12 months. Hospital admissions and
use of medications were recorded through electronic patient files. Patients also completed
the Short-Form Health and Labour Questionnaire at baseline, 6 months and 12 months.

Costs
A cost-effectiveness analysis was completed alongside the randomised controlled trial.

REFERENCES
 Greving JP. Kaasjager HAH. Vernooij JWP. Hovens MMC. Wierdsma J. Grandjean
HMH. van der Graaf Y. de Wit GA. Visseren FLJ. Cost-effectiveness of a nurse-led
internet-based vascular risk factor management programme: economic evaluation
alongside a randomised controlled clinical trial. BMJ Open 2015, 5: e007128

 Vernooij JWP. Kaasjager HAH. van der Graaf Y. Wierdsma J. Grandjean HMH.
Hovens MMC. de Wit GA. Visseren FLJ. On behalf of the SMART study group.
Internet based vascular risk factor management for patients with clinically manifest
vascular disease: randomised controlled trial. BMJ 2012, 344: e3750

International CVD Prevention Case Study Report Page | 95

Appendix 7: Canada CHAP Program

CARDIOVASCULAR HEALTH AWARENESS

PROGRAM (CHAP)

A CASE STUDY
PROGRAMME AT A GLANCE
The Cardiovascular Health Awareness Program (CHAP) was
developed in Ontario, Canada. CHAP aims to improve the
process of care related to the cardiovascular health of older
adults.
CHAP started as a research study piloting a community
based model of cardiovascular disease (CVD) prevention in
two communities. CHAP encourages older people to
become more aware of their cardiovascular risk and to
acquire self-management skills. Key elements are: KEY TAKEAWAYS
 Free cardiovascular risk assessment and education
sessions held in community pharmacies  A community-driven
 Family physicians invite their patients over 65 to and owned initiative
attend and sessions are also advertised in the local
community  Using aged matched
 Sessions are run by volunteer peer health educators volunteers considered
 Community Health Nurses train the volunteers, very important for the
provide quality control and are on call to assess community intervention
people with elevated blood pressure to be seen as peer
 During the sessions volunteers assist patients to take advice not medical
and record their blood pressure using an automated advice
device and complete a CVD risk profile (based on
blood pressure, previous hypertension diagnosis and  Use of personalised
lifestyle risk factors) invitation letters
 Patients are told about the importance of reducing resulted in the highest
lifestyle CVD risk factors and signposted to attendance numbers
community agencies and resources for support
 Family physicians receive feedback on patients  Designed as a
attending sessions scalable, sustainable
service that can be
CHAP is a community-driven and community-owned tailored to different
initiative. It is designed to be a scalable service that target groups
minimises centralised support over time to achieve a long-
term sustainable service. Since it began, the CHAP model
has also been applied in a range of different types of
communities where it is tailored to maximise participation
from the target group. For example:
 South Asian community in Ontario, Canada
 Rural community in Alberta, Canada
 Social housing developments in Ontario, Canada
 Rural community in the Philippines

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TARGET POPULATION
People aged ≥65 years who are community Family Physicians
dwelling and mobile.  47% of family physicians participated
in the two pilot communities
BENEFITS AND OUTCOMES  99% of family physicians participated
in 20 communities with 63% actively
A randomised controlled trial comparing 20 encouraging their patients to attend
CHAP communities with 19 control sessions
communities has found:  The programme provided office
 Exposure to CHAP was associated assistance to some practices in
with a 9% relative reduction in a producing lists of patients to be
composite measure of hospital invited to a CHAP session
admissions for acute myocardial
Pharmacies
infarction, stroke and congestive
heart failure. This was equated to  79% of pharmacies participated in
3.02 fewer annual hospital the two pilot communities
admissions per 1,000 people aged  89% of pharmacies participated in 20
≥65 communities
 No significant difference in all-cause  Challenges experienced included the
mortality or in-hospital death from busy pharmacy environment and
CVD limited or inadequate space.
Solutions included attempting to set
A longitudinal study of 13,596 people who up sessions in quieter areas,
attended ≥2 CHAP sessions in 22 recruiting alternative pharmacies or
communities has found: working within the constraints
 Average blood pressure for patients Patients
with initially high blood pressure  39% of invited people attended a
improved from 142/78mmHg to session in the two pilot communities
123/69mmHg over the 18-months (from 2,493 invitations sent)
follow-up  66% of invited people attended a
 The authors suggest that a decrease session in 20 communities (from
of 10/5mmHg reduces the risk of 24,196 invitations sent). 43% of
developing heart failure by about people attended two or more
50%, stroke by 38%, heart attack by sessions
15% and death by 10%  Use of personalised invitation letters
resulted in higher attendance
PROGRAMME EXPERIENCES  Challenges included a tendency for
patients to arrive all together at the
Peer Health Educators start of sessions. The solution was to
 577 peer health educators divide sessions into 2 time slots
(volunteers) were trained to deliver  Another challenge was a lack of
CHAP in 20 communities adherence to protocol (i.e. talking or
 11 of 20 participating communities moving whilst taking blood pressure).
re-allocated funds to hire an assistant The solution was to reinforce the
coordinator to supervise concurrent need for volunteers to monitor
sessions, manage volunteers and/or patients
help the local coordinator  The use of aged matched peer
 Approximately half of the 20 volunteers was viewed as important
participating communities provided in the programme, being seen as
additional support to volunteers e.g. peer advice rather than medical
refresher training and meetings to advice
discuss problem areas

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THE DETAIL
Context
The CHAP model focuses on the management of CVD risk, particularly hypertension and
was first used in 39 communities in Ontario targeting the older ≥65 age group. Subsequently
the model has been used to targeted CVD risk reduction in a variety of populations.

Goals, Values and Principles

CHAP is a community-based approach that encourages people to become more aware of
their cardiovascular risk, link with a range of community and health care supports and
agencies and acquire self-management skills.

The objective of CHAP is to improve the process of care related to the cardiovascular health
of older adults in Ontario, Canada and shift the distribution of risk at the population level.

The CHAP programme integrates primary care and existing community resources to provide
cardiovascular risk assessment including repeated accurate measurement of blood pressure
among older adults. CHAP aims to overcome poor/selective uptake and improve follow-up
(‘closing the loop’).

CHAP was developed as a low cost, community-driven initiative with the aim of minimising
centralised support over time to achieve a long-term sustainable community-owned
programme. CHAP is designed to be:

 A scalable programme that could be implemented system wide

 Inexpensive, quick and easy to implement in any community

Population
Thirty nine communities in Ontario involved, not including two communities where the
programme was piloted. The total population in 2005 was 973,246 including 140,642 people
aged ≥65 years. Community size ranged from 10,000 to 60,000. Communities had five or
more family physicians and two or more pharmacies. Currently nine of the communities have
integrated CHAP as one of the regular community programmes.

In the study assessing the effectiveness of CHAP, 20 communities were allocated to receive
CHAP and 19 communities acted as controls. People aged ≥65 years were invited to attend
community pharmacy CHAP sessions. Family physicians were asked to identify people who
had visited their practice at least once in the last 12 months and who were community
dwelling and mobile.

Service Delivery
The CHAP working group was originally formed in 2000. The components of the CHAP
programme were developed through various pilots and community-wide demonstrations to
develop a standardised programme implementation guide with a toolkit of downloadable
resources and templates.

Community CVD Risk Awareness Sessions:

 Free awareness sessions were held in community pharmacies. Generally three hour
sessions but some pharmacies offered extended sessions. The typical duration for an
individual patient was 20 minutes

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 Volunteer peer health educators ran the sessions (at least three volunteers per session)
and Community Health Nurses provided quality control and trained volunteer peer health
educators and mentors
 Community-based family physicians referred patients to awareness sessions and
received feedback on patients attending them. The programme was also advertised in
the community through local media and posters in pharmacies and primary care
practices
 During the sessions volunteers assisted patients to take and record their blood pressure
using an automated device and complete a CVD risk profile. The volunteers also
distributed information about community resources and health-related topics to support
people in changing lifestyle which may impact on their CVD risk. A community health
nurse is on called to assess people with elevated blood pressure and people are advised
to see their physician or pharmacist if appropriate. Reports were also sent to the family
physician with permission
 CVD risk factors collected at baseline include age, gender, BMI, blood pressure, history
of transient ischemic attack, stroke, heart attack, high cholesterol and high blood
pressure, smoking status, drinking habits, eating habits (high fat food, vegetables, fruit,
salt), stress level, physical exercise, and whether they lived alone
 People of any age attending a pharmacy could be assessed, but people aged ≥65 years
were targeted

Outcomes
Multiple publications present details of the programme and its implementation and outcomes
from early implementation in 2003 to roll-out to 20 CHAP areas. The CHAP programme was
also evaluated through a cluster randomised controlled trial (in 2006) and there has been
ongoing work looking at wider implementation.

Early outcomes of the community health awareness program in 2003 (Chambers et al 2005)
 56 sessions held in 27 community pharmacies
 79% of eligible pharmacies and 47% of eligible family physicians participated in CHAP
 983 of 2,493 invited patients (39%) attended a session. 59% returned for a 2nd pharmacy
session. Average age 74.8 years, 53% female. All patients agreed for their results to be
sent to their physician
 Positive feedback from volunteers and pharmacists

Challenges faced by the cardiovascular health awareness program and approaches to

resolving these:

Peer Health Educators

 Challenge: some media and community organisations refused to promote the
programme without funding. Solution: approached alternative media and community
organisations

 Challenge: Inability to give volunteers advance notice regarding pharmacy session

locations and times. Solutions: provided explanation and recruited a surplus of
volunteers

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Family Physicians
 Challenge: Unwillingness to participate after initial agreement. Solution: recruited
additional physicians
 Challenge: Overloaded with work or inaccessible. Solution: recruited alternative
physicians
 Challenge: Inability to produce patient lists. Solution: assisted office staff to produce lists;
if this failed, recruited alternative physicians

Pharmacies
 Challenge: Busy environment with high levels of customer traffic. Solution: Attempted to
set up sessions in unobtrusive areas
 Challenge: Limited or inadequate space. Solution: recruited alternative pharmacies or
worked within constraints

Patients
 Challenge: Tendency to arrive all at the same time, at the start of sessions. Solution:
Divided sessions into two time slots
 Challenge: Lack of adherence to protocol (i.e. patients talked or moved whilst blood
pressure being taken). Solution: Reinforced need for volunteers to monitor patients

Experiences of implementing the CHAP community health awareness program in 20

communities (Carter et al 2009)
 338 (99%) family physicians participated with 16 opinion leaders identified. 97% received
feedback on patients who attended sessions. 214 (63%) actively encouraged their
patients to attend CHAP sessions
 129 (89%) pharmacies participated. 16 champions identified
 595 volunteer peer health educators recruited and 577 (97%) trained
 Invitations sent to 24,196 people. 27,358 blood pressure measurements taken from
15,889 patients (66%). 43% of patients made two or more visits. Use of personalised
invitation letters resulted in the highest attendance numbers
 1,488 (9%) patients were referred to family physicians for follow-up. 570 (4%) followed-
up by on-call community health nurse who completed 559 assessments. 554 (4%)
referred to pharmacist, of whom 2016 (37% of those referred) had medication
assessment completed by pharmacist

Amendments made to processes included:

 11/20 communities re-allocated funds to hire an assistant coordinator to supervise

concurrent sessions, manage volunteers and/or help the local coordinator at high traffic
sessions
 In three communities the nurse was present for the whole session (rather than being on
call)
 Approximately half of the communities provided additional support to volunteers e.g.
refresher training, meetings to discuss problem areas and collaborative development of
solutions and/or to recognise volunteer contributions

Key factors in programme success:

 Community and organisational factors

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 Guidance and support by the advisory group
 Devolution of responsibility to communities
 Community mobilisation and recruitment of physicians and pharmacists
 Support for volunteer led activities
 Protocols for participants at high risk of CVD and availability of health professional for
support
 Accurately tracking participation and community-level data
 Providing results to family physicians and pharmacists
 Achieving a balance of standardised programme process and flexibility to fit the specific
community context

Findings of the community cluster randomised trial of CHAP with impact on hospitalisations
(Kaczorowski et al 2011)
Twenty communities randomised to provide CHAP and 19 communities to no intervention
controls. Communities stratified by population size and geographical location. In CHAP
communities residents aged ≥65 were invited to volunteer to run cardiovascular risk
assessment and education sessions (also known as awareness sessions) held in community
pharmacies over a 10 week period (see below for further details). In both arms, usual health
promotion and care services were available to residents. The primary outcome was a
composite of hospital admissions for acute myocardial infarction, stroke and congestive
heart failure in the year before and year after CHAP. Relative rates were calculated (event
rates for intervention communities compared to control communities):

 The mean age of residents in both intervention and control communities was 75 and the
mean proportion of men was 43% in both groups
 Exposure to CHAP was associated with a 9% relative reduction in the composite primary
endpoint (rate ratio 0.91, 95%CI 0.86 to 0.97, p=0.002) or 3.02 fewer annual hospital
admissions per 1,000 people aged ≥65
 There were also statistically significant reductions favouring the intervention for acute
myocardial infarction (rate ratio 0.87, 95%CI 0.79 to 0.97, p=0.008) and congestive heart
failure (rate ratio 0.90, 95%CI 0.81 to 0.99, p=0.029)
 There was no significant difference for stroke (rate ratio 0.99, 95%CI 0.88 to 1.12,
p=0.89)
 When calculated as number of unique people admitted to hospital there was a significant
difference favouring CHAP in those with newly prescribed antihypertensive drug
treatment (rate ratio 1.10, 95%CI 1.02 to 1.20, p=0.02)
 There was no significant difference in all-cause mortality (rate ratio 0.98, 95%CI 0.92 to
1.03, p=0.38) or in-hospital death from CVD (rate ratio 0.86, 95%CI 0.73 to 1.01, p=0.06)
 In the year after the intervention public health units and agencies in the study areas were
contacted to assess potential co-intervention or contamination from any other
cardiovascular health initiatives during the study period. No other such initiatives were
identified

Longitudinal cohort study on the impact of CHAP in reducing blood pressure for people
attending CHAP sessions between 2008 and 2010 (Ye et al 2013)
This study included 13,596 people who attended CHAP sessions between 2008 and 2010.
Sessions were delivered weekly in 22 communities after the completion of the cluster RCT
using the same CHAP process. Participants were divided into three groups for analysis:
attendance at one session (n=9,531), attendance at two sessions (n=1,567), attendance at >

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2 sessions (n=2,498). Only patients with more than two visits were used for the longitudinal
analysis. The average age was 67 years and 37% were male:

 The proportion of patients with high blood pressure at baseline was 28.8% who attended
1 visit, 27.4% for those attending 2 visits and 32.2% for those attending >2 visits
 For participants with initially high blood pressure, systolic blood pressure (SBP) dropped
by 0.79% and diastolic blood pressure (DBP) by 0.71% every month in CHAP (SBP ratio
0.992, 95%CI 0.991 to 0.994, p<0.01; DSP ratio 0.993, 95%CI 0.991 to 0.994, p<0.01)
 Average blood pressure for the high blood pressure group improved from 142/78mmHg
to 123/69mmHg over the 18-month period
 The authors reported that a decrease in blood pressure of 10/5mmHg reduces the risk of
developing heart failure by about 50%, stroke by 38%, heart attack by 15% and death by
10% (referencing Hypertension Canada)
 There was no significant change in SBP and DBP for people without high blood pressure
at baseline
 Older adults who lived alone, had hypertension at baseline, reported healthier eating
habits and presented with a higher SBP at baseline were more likely to attend more than
one session

Leadership and Governance

The programme is a collaboration of family physicians, pharmacists, public health authorities
and their personnel, community organisations e.g. the Kidney Foundation of Canada and
trained volunteer peer health educators working within a community setting.

The CHAP Working Group provided centralised support at all stages of programme delivery,
including a launch meeting, weekly teleconferences with local coordinators, monthly
newsletters, an interactive web forum and site visits to assist with recruitment and promotion.
Programme coordination was done by Local Lead Community Organisations.

The use of a cluster RCT to evaluate the programme required consistency of delivery across
the 20 sites. However, standardisation needed to be balanced with flexibility to varying
contexts and resources of individual communities e.g. in support, processes, materials and
resources.

Finances
A 2005 publication states that the programme is funded in part by the Canadian Institutes of
Health Research, by a contract with the Ministry of Health and Long-Term Care,
Government of Ontario and by The Team for Individualizing Pharmacotherapy in Primary
Care for Seniors. The Kidney Foundation is also acknowledged for contributions in kind for
coordinating older adult volunteers.

Government Investment included:

 CHAP programme development: Ontario Stroke Strategy and Ontario Ministry of Health
Promotion - $2.3 million 2004-2011
 CHAP evaluation: Canadian Stroke Strategy ; Canadian Institutes of Health Research;
Host organisations including Institute for Clinical Evaluative Science - >$2 million 2001-
2012

In the cluster RCT, lead organisations were asked to submit proposals for up to $5,000 in
funding to lead a 2-month community mobilisation phase (26 agencies from the 20

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communities applied, with agencies ranging from the local hospital to the YMCA and Meals
on Wheels). Organisations were then invited to submit proposals to implement CHAP (20
agencies in the 20 communities applied). Funding was calculated according to the
population size of the community and the proposed scope of the programme. Communities
received between $20,000 and $40,000 to support the implementation of CHAP. (In the
2011 paper $20,000 is given as equivalent to £13,000).

Funding agreements were re-negotiated during the project in several cases to respond to
local challenges and circumstances (figures not provided).

Costs (Goree et al 2013)

Resource use and cost consequences of CHAP (Canadian dollars):

 Average cost $30,494 per community (£17,007) across all intervention communities
 Cost varied from $11,976 to $57,113 (£6,680 - £31,855) depending on community size,
internal volunteer support and availability of ‘in-kind’ infrastructure support
 CHAP central costs $804,304 (£448,521) – an average of $40,215 (£22,425) per
community for a one year time period
 Overall this equated to approx. $71,000 (£39,591) per community or $20.20 (£11.26) per
older adult resident

The additional cost of the CHAP intervention (i.e. $20.20perresident)was offset by slightly
lower health care costs in the intervention communities such that the total cost in the year
after the intervention was equal in both groups at approximately$4200perelderlyresident
(mean cost difference -$1.69; 95%CI -$156.76 to -$152.39; p= 0.982).

Costs from a CHAP Pragmatic Trial (screening, referral, education, pharmacy support for
elderly hypertensives) to reduce CVD hospital admissions plus death from any cause: $1.4
million in 2007 (£780,678); cost per patient $10 (£5.58) for 140,642 over 65 year olds or
$110 (£61.33) for 13,379 screened.

(Sterling costs calculated using March 2018 exchange rate)

Human Resources
Community pharmacies provided awareness sessions using volunteer peer health educators
and mentors with support from community health nurses and community-based family
physicians. Volunteers included retired nurses, (about 50% of the volunteers), health
professionals trained outside of Canada, and aspiring medical students.

Pharmacists were asked to hold at least two CHAP sessions. Volunteers were asked to
attend at least two awareness sessions (in addition to training sessions).

Two regional coordinators, each covering 10 CHAP communities, provided regular support
to local CHAP coordinators who were responsible for operating CHAP in their respective
communities. CHAP sessions at different pharmacies were scheduled on different days.

The contribution of family physician opinion leaders was seen as fundamental in achieving a
high rate of participation by family physicians. Actions included sending personalised letters,
speaking at hospital rounds and/or contacting colleagues directly to discuss potential
concerns/questions.

Infrastructure and Supplies

Centralised services include preparation of data forms, posters and press release templates,
provision of the CHAP Implementation Guide, with week-by-week guidance plus

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downloadable customisable materials for volunteer recruitment and communications, and
electronic data management services.

Community pharmacy awareness sessions run by volunteers required the recruitment and
training of volunteers in the use of blood pressure monitors.. Volunteers were recruited by a
peer health educator coordinator through liaison with community organisations, seniors
groups and advertising in local media.

GPs were also required to send invitation letters sent to people aged ≥65, identified and
were reimbursed for this activity.

Knowledge and Information

Training
Volunteers for the pharmacy awareness sessions were trained by a community health nurse
in three sessions using a standardised training package, with topics on cardiovascular health
awareness, healthy eating, physical activity, stress management and cardiovascular health
and high blood pressure, and practice in the setting up and operation of the pharmacy
session including the use of the blood pressure monitoring devices.

An ‘enhanced educator’ training module was created to support skill development for
volunteers with a background or interest in providing additional health resources and peer-
counselling. This training was not consistently delivered due to time constraints.

Data
Data collected at pharmacy awareness sessions are sent to a computerized database (run
by a data management company), with patient consent. The software prepares a tailored
patient report that is sent to the family physician. These reports rank patients by their most
recent systolic blood pressure within diagnostic/treatment groups (i.e. potentially new cases
of hypertension, and potentially under-treated, non-adherent patients) and reflect different
blood pressure targets for patients with diabetes. Family physicians also get an overview
report six months later with the percentage of patients in their practice with high blood
pressure and who reached systolic blood pressure target levels compared to other
anonymised practices.

Community health nurses document assessments of high-risk participants on a standardised

form which includes confirmation of the high blood pressure, assesses possible contributing
factors and documents actions to ensure appropriate follow-up.

The pharmacist on duty during CHAP sessions documents consultations with high-risk
patients using a standardised form focusing on determining whether high blood pressure
was due to sub-optimal drug therapy or adherence issues.

A secure web portal to community-specific databases allows local coordinators to schedule

sessions, manage volunteers and input and track physician and pharmacy participation.

In addition:

 Participating communities produced a report on implementation using a standardised

template, designed to elicit common successes and challenges
 Telephone interviews were conducted with local coordinators in all 20 CHAP
communities
 Community CHAP partners, pharmacists, family physicians and local lead organisation
staff participated in a post-program debriefing meeting to discuss facilitators and barriers

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 to implementation and characteristics essential for successful implementation. This was
used to plan for a sustainable long-term programme model
 Data on outcomes for the RCT was taken from hospital discharge abstracts, physician
service claims from an insurance programme and prescription drug claims. These were
described as having high levels of completeness and validity

REFERENCES
 Carter M. Karwalajtys T. Chambers L. Kaczorowski J. Dolovich L. Gierman T. Cross
D. Laryea S. for the CHAP Working Group. Implementing a standardized community-
based cardiovascular risk assessment programme in 20 Ontario communities. Health
Promotion International 2009, 24(4): 325-333
 Chambers LW. Dolovich L. Kaczorowski J. Thabane L. on behalf of the CHAP
working Group. Session on Primary Care and Chronic Diseases: ICES
Cardiovascular Research Day. June 2012
 Chambers LW. Kaczorowski J. Dolovich L. Karwalajtys T. Hall HL. McDonough B.
Hogg W. Farrell B. Hendricks A. Levitt C. A community-based program for
Cardiovascular Health Awareness. Revue Canadienne de Santé Publique 2005,
96(4): 294-298
 Kaczorowski J. Interview with SPH, February 2018
 Kaczorowski J. Chambers LW. Dolovich L. Paterson JM. Karwalajtys T. Gierman T.
Farrell B. McDonough B. Thabane L. Tu K. Zagorski B. Goreree R. Levitt CA. Hogg
W. Laryea S. Carter MA. Cross D. Sabaldt RJ. Improving cardiovascular health at
population level: 39 community cluster randomised trial of Cardiovascular Health
Awareness Program (CHAP). BMJ 2011, 342:d442
 Ye C. Foster G. Kaczorowski J. Chambers LW. Angeles R. Marzanek-Lefebvre F.
Laryea S. Thabane L. Dolovich L. The impact of a cardiovascular health awareness
program (CHAP) on reducing blood pressure: a prospective cohort study. BMC
Public Health 2013, 13: 1230
 Goeree R, vonKeyserlingk C, , Burke N, , He JKaczorowski, J Economic Appraisal of
a Community-Wide Cardiovascular Health Awareness Program VA L U E IN HE
ALTH 1 6 ( 2 0 1 3 ) 3 9 – 4 5

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Appendix 8: Healthy Japan 21

Healthy Japan 21:

Life style intervention for Metabolic Syndrome and
cardio-metabolic risk factors A CASE STUDY
PROGRAMME AT A GLANCE
As part of the Healthy Japan 21 strategy, Japan has
embarked on a national health policy change to prevent
lifestyle-related diseases, including cardiovascular disease
(CVD) and diabetes. National legislation requires employers
and local governments to offer annual ‘health check-ups’
focussed on CVD, cancer and life style risk factors. There
are financial incentives for employers, so uptake is typically
high.
The basic health check-up includes: a blood pressure test,
waist circumference, height and weight, blood tests (lipids,
triglycerides, HDL and LDL cholesterol, blood sugar (HbA1c, KEY TAKEAWAYS
fasting blood sugar), hepatic function, red blood cell count,
haemoglobin level, haematocrit), electrocardiogram and  Annual testing detects
urine tests for chronic kidney disease. A questionnaire about CVD risk
lifestyle is focused on diet, tobacco smoking, physical
activity, work life balance and family history of disease.  For those at risk of
Results of tests are graded A to D and sent to individuals CVD or metabolic
and their employer (if the test was provided by the syndrome lifestyle
employer). For those at risk of CVD or metabolic syndrome: behaviour change
sessions are offered
 Sessions of 20 minutes or more for each individual
or 80 minutes or more to a group, by a physician,  Education information
public health nurse or registered dietician, were and goal setting are
offered key elements of the
 In the sessions a facilitator provides motivational sessions
support, explains the necessity of lifestyle
improvement, the relationship between lifestyle and  Follow up support may
the health check-up data and the person’s lifestyle be offered and at six
 An explanation was given about the advantages of months the progress
lifestyle improvement and the disadvantages of towards meeting goals
failing to improve lifestyle is checked
 The facilitator suggested changes needed to improve
the lifestyle (e.g. diet and exercise) and set goals for
actions and signposted people to community
resources for support
 The facilitator showed how to measure body weight
and abdominal circumference
 A follow-up interview was performed if the facilitator
and participant felt it would be helpful
 An evaluation of progress via interview, telephone or
other method was carried out six months after the
first session

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TARGET POPULATION
All people over the age of one year are Clinically relevant reduction in
eligible to have an annual health check-up BMI(>5%) intervention versus no
and are part of the Healthy Japan 21 risk
intervention odds ratio1.36(95% CI1.33 to
reduction programme. This case study
focusses on lifestyle change interventions 1.38) p<0.001
offered to those aged 40-74 with a risk of
CVD or metabolic syndrome. Reversal of metabolic syndrome
intervention versus no intervention odds
ratio 1.31(95% CI 1.29 to 1.33) p<0.001
BENEFITS AND OUTCOMES
 High uptake of annual health checks-ups,
as this is it is a mandatory offer to the CHALLENGES AND
population and employers are offered SOLUTIONS
incentives to ensure a high uptake
 Employers receive the results of tests
 Individuals have continuous awareness and can call a meeting with an employee
of areas where improvements in health to ask how they will address the areas
could be made as they are screened where they didn’t achieve an ‘A’ grade
annually
 Current workplace culture does not
 Community based activities support always match the actions required of
change in behaviour and are employees e.g. consumption of alcohol
implemented locally expected at work events

 Optional focused lifestyle change support

is offered to those with test results where
risk factors are identified and are
considered to be effective by those
evaluating the outcomes

 People who took up the offer of lifestyle

change support following health check-
ups, compared to those who did not, had
clinically significant reductions in systolic
blood pressure, waist circumference and
BMI, an effect which was still apparent at
three years follow up

Outcomes from lifestyle change

intervention:

Clinically relevant reduction in waist

circumference (>5%) intervention versus
no intervention, odds ratio 1.33(95%
CI1.31 to 1.36) p<0.001

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THE DETAIL
Context
Despite previous national health promotion programmes in Japan, lifestyle-related diseases
still remained a major cause of death. The combination of a rapidly ageing society and
declining birth rates led to fears that lifestyle related diseases would increase healthcare
costs and the burden of nursing care in the 21st century. Healthy Japan 21 was established
to create a society where all nationals can live healthy and fulfilling lives.

The 4 basic policies are:

 The importance of prevention

 Creation of a supportive environment for the enhancement of health
 Goal setting and assessment
 The promotion of effective well-coordinated activities by the various implementing bodies

Goals, Values and Principles

The aim of Healthy Japan 21 is to reduce late-middle age deaths, to extend healthy life
expectancy and to improve quality of life. Since April 2008, Japan has embarked on a
national health policy change to prevent lifestyle-related diseases, such as CVD and
diabetes, involving health check-ups and the invitation to participate in a lifestyle change
programme if specific risk factors are detected, which is the focus of this case study. This
case study is focused on interventions to reduce metabolic syndrome and cardio-metabolic
risk factors. A wide range of information is gathered from screening tests and questionnaires
completed by the individual.

Population
This is a national programme targeted at the whole population from age 1 year, all whom are
eligible for annual health check-ups.

Service Delivery
Healthy Japan 21 included 70 specific goals in nine focus areas; six related to lifestyle and
three directly related to high risk conditions for CVD. These were: diet and nutrition, physical
activity and exercise, leisure and mental health, smoking, alcohol, dental health, diabetes,
cardiovascular disease and cancer.

This particular case study focuses on offering lifestyle change interventions for people who
have been identified via the annual health check to have a high risk of CVD or metabolic
syndrome.

Where people did not meet the following target values, lifestyle change interventions were
offered:

 Waist circumference >85 cm (men)/>90 cm (women) as a measure of abdominal obesity

 Waist circumference <85 cm (men)/<90 cm (women) with a body mass index >25
kg/m2, with at least one of the following: (1) high glucose tolerance (fasting blood
glucose >100 mg/dl or haemoglobin A1c _5.6%), (2) dyslipidaemia (triglyceride >150
mg/dl or high-density lipoprotein-cholesterol <40 mg/dl), (3) high blood pressure (systolic
blood pressure >130 mm Hg or diastolic blood pressure >85 mm Hg)

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The risk stratification table below indicates the level of support people are offered based on
their health check-up results.

Table 1: Stratification of lifestyle intervention by risk(Nakao et al 2018)

Abdominal obesity Risks Smoking Age

(Waist circumference ≥85cm 1.High BP 40-64 65-74

in men and ≥ 90 cm in
women) 2.Dislipedemia

3.High FBG

No abdominal obesity Any risk Yes or no Written information

BMI <25kg/m2

Abdominal obesity ≥2 risks Yes or no Positive Intensive

support support
BMI <25kg/m2 1 risk Yes

No Written information

No abdominal obesity 3 risks Yes or no Positive Intensive

support support
BMI≥25kg/m2 2 risks Yes

No Written information

1 risk Yes or no

BP, Blood pressure, FBG, Fasting blood glucose, BMI, body mass index

Written information
Regardless of the presence/absence of the need of lifestyle intervention, written information
is supplied to all people receiving this specific health check-up once a year (simultaneously
with notification of the check-up results). It provides information tailored to individual subjects
based on the health check-up data and responses to the questionnaire filled in at the time of
the check-up.

Lifestyle intervention (positive support)

Support is provided to help the individual become aware of the lifestyle factors that require
improvement, and of the factors which should be further considered.

The person is guided to take actions towards achieving their goals during a session lasting
20 minutes or more. If it is a group session this takes 80 minutes or more (eight individuals
or less per group) at which an action plan is prepared.

On the basis of the specific health check-up data and the results of the questionnaire carried
out to determine the status of lifestyle (smoking, exercise, diet, rest, etc.), support is
provided by a one to one or group session and the results (evaluation made six months
after the date of preparation of the action plan) are evaluated.

Lifestyle intervention (intensive support)

At the beginning, support is provided by a face to face session, followed by continuous
support for three months or longer. Each session is for 20 minutes or more when provided to

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each individual separately and for 80 minutes or more when provided to groups (8
individuals or less/group).

On the basis of the specific health check-up data and results of the survey carried out to
determine lifestyle status (smoking, exercise, diet, rest, etc.), support sessions are provided,
and the progress of the action plan implementation (interim evaluation) and the results (six
months after the date of preparation of the action plan) are evaluated.

Content of lifestyle intervention sessions

Interventions were provided for 20 minutes or more to each individual separately or for 80
minutes or more to a group by a physician, public health nurse, or registered dietician.

 The facilitator explained the necessity of lifestyle improvement, the relationship between
lifestyle and the specific health check-up data, the patient's lifestyle, knowledge about
metabolic syndrome and lifestyle-related chronic diseases, and the influence of these
factors on the daily lives of the individuals receiving the motivational support
 Explanation was given about the advantages of lifestyle improvement and the
disadvantages of failing to improve lifestyle
 The facilitator suggested changes needed to improve the lifestyle (e.g. diet and exercise)
 The facilitator set goals for actions and the timing of the outcome evaluation,
accompanied by a discussion of the social resources available and needed for lifestyle
improvement
 The facilitator showed how to measure body weight and abdominal circumference
 Goals for actions and the action plan were prepared by the individual receiving the
motivational support under guidance via the sessions
 A follow-up session was undertaken if helpful for the participant and thought beneficial by
the facilitator
 The evaluation was made via interview or other method (telephone, e-mail, etc.), six
months after the first session

Outcomes
One nationwide cohort study (Nakao et al 2018), looked at the effectiveness of these lifestyle
change interventions offered to people identified as being at high risk of metabolic syndrome
and cardiovascular disease. Known as the Metabolic Syndrome and Comprehensive
Lifestyle Intervention Study (MetS ACTION-J), researchers used the data from the National
Database of Health Insurance Claims and Specific Health Check-ups of Japan (NDB). The
national data captured examination records and laboratory data to diagnose metabolic
syndrome (MetS). Anonymised data regarding subjects who underwent a health check-up
between year 2008-09 and 2011-12 from the Ministry of Health, Labour and Welfare
(MHLW) was extracted. The main findings are:

 Clinically relevant reductions, i.e. >5% at year 3, were achieved in a significantly higher
percentage of participants of the lifestyle intervention compared to non-participants
(Waist circumference (WC), 21.4% vs 16.1% and BMI, 17.6% vs 13.6%; p<0.001, each)
 Higher weight reductions (>10%) were also observed in a significantly higher percentage
of participants
 Both abdominal and overall obesity, measured by categorical weight reductions,
improved significantly more in participants compared to non-participants
 Participants who received lifestyle intervention had significantly more improvements in
MetS, as compared with non-participants who did not receive a lifestyle intervention

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 (reversal of MetS: 47.0% vs. 41.5%, p<0.001). After adjusting for confounders, lifestyle
intervention was associated with an adjusted odds ratio (OR) of 1.33 (95% confidence
interval [CI]: 1.31 to 1.36, p<0.001) for 5% reduction in WC; 1.36 (95% CI 1.33 to 1.38,
p<0.001) for 5% reduction in BMI; and 1.31 (95% CI: 1.29 to 1.33, p<0.001) for reversal
of MetS)
 The mean WC changes were −1.34 and −0.44 cm in participants and non-participants,
respectively, with a difference of −0.89 cm (95% CI: −0.92 to −0.86)
 The mean BMI changes were −0.29 and −0.08 kg/m2 in participants and non-
participants, respectively, with a difference of −0.22 kg/m2 (95% CI: −0.22 to −0.21)
 The intervention program also resulted in significantly greater reductions in both
abdominal and overall obesity parameters
 Participants, compared to non-participants, had significant reductions in systolic blood
pressure (SBP, −1.15 vs −0.72 mm Hg), diastolic blood pressure (DBP, −0.97 vs −0.64
mm Hg)
 Participants also improved their HDL-cholesterol level more than non-participants (-1.48
vs -0.94 mg/dl)

Further results from the National Health and Nutrition Survey are available from the website
of Health Japan 21. The second phase started in 2013 with new targets for 2022 which are
outlined in the table below.

Table 2 National Health and Nutrition Survey results and targets to 2022 (Udagawa K
2008)
Measure 2010 2011 2012 2013 2014 2015 2022
target

Average SBP pressure 138 138 137 138 137 136 134
(mmHg) men 40-89 years

Average SBP (mmHg) 133 133 131 133 132 130 129
women 40-89 years

Total cholesterol >240mg 13.8% 10.7% 10.8% 11.3% 12.0% 10.4% 10%
/dL men 40-79 years

Total cholesterol >240mg 22.0% 20.3% 17.5% 19.9% 20.2% 20.9% 17%
/dL women 40-79 years

LDL cholesterol >160mg 8.3% 8.0% 7.5% 8.4% 7.6% 8.3% 6.2%
/dL men 40-79 years

LDL cholesterol >160mg 11.7% 13.6% 11.0% 11.7% 12.8% 12.7% 8.8%
/dL women 40-79 years

Individuals maintaining 31.2% 31.7% 29.6% 29.0% 30.2% 31.6% 31.2%

ideal body weight
(BMI>18.5<25) men 20-
60 years

Individuals maintaining 22.2% 23.0% 20.5% 19.6% 22.2% 20.5% 22.2%

ideal body weight
(BMI>18.5<25) women

International CVD Prevention Case Study Report Page | 111

40-60 years

Mean salt intake (g) 10.6 10.4 10.4 10.2 10.0 10.0 8.0
(adults >20 years)

Mean daily intake 282 277 287 283 292 294 350
vegetables (g) (adults
>20 years)

Individuals consuming 61.4% 61.4% 58.9% 56.4% 58.8% 57.2% 30%

<100g fruit/ day (adults
>20 years)

Smoking (adults >20 19.5% 20.1% 20.7% 19.3% 19.6% 18.2% 12%
years)

Individuals who regularly 26.3% 25.9% 26.5% 22.3% 20.9% 24.6% 36%
exercise men 20-64 years

Individuals who regularly 22.9% 24.8% 21.5% 19.4% 17.5% 19.8% 33%
exercise women 20-64
years

Individuals who regularly 47.6% 47.4% 49.6% 47.6% 42.4% 52.5% 58%
exercise men >65 years

Individuals who regularly 37.6% 36.2% 39.4% 37.8% 35.7% 38.0% 48%
exercise women >65
years

2012 2013 2014 2015 2016 2022

target

Number of registered companies 14 65 67 91 95 100

that supply food products low in salt
and fat

Number of restaurants that supply 17284 n/a 21163 23322 25388 30000
food products low in salt and fat

Number of local governments who 17 29 26 30 47

offer community development and
environments to promote physical
activity

SBP, systolic blood pressure, LDL, low density lipoprotein, BMI, body mass index

Leadership and Governance

The programme was launched by the Ministry of Health and Welfare as a national health
promotion movement. A Health Promotion Law was passed in 2002 to enhance health
promotion measures, stipulating that each prefecture/ municipality in Japan should establish

International CVD Prevention Case Study Report Page | 112

health promotion plans under the basic policies of Healthy Japan 21. There are 47 local
government areas (prefectures).

Organisations responsible for implementation, including local public organisations, were

expected to formulate common goals amongst participating organisations which are relevant
to their actual situations but consistent with the overall goals of Healthy Japan 21.

Specific plans for the promotion of health were to be formulated in the manner best suited to
the local area by enlisting the co-operation of residents and various community health
organisations to promote the plan.

Finances
Local governments assumed the main responsibility for financing health promotion. A
financial adjustment policy was implemented in the form of financial assistance from national
to local governments, to account for variation in the availability of local revenues. This policy
aimed to balance revenues of local governments and ensure a minimum level of public
health services was provided equally across the country.

In April 2008, a decision was made to finance disease prevention with Japan’s social health
insurance scheme that aims to help individuals to have control over their own health. The
universality of social health insurance coverage is an important factor for Japan.

Social health insurance also facilitates effective integration of health promotion into health
service delivery and financing arrangements.

Human Resources
Health promoting leaders have been identified and nominated by community members and
trained to conduct health promoting activities in their communities. These include advocacy
of healthy lifestyle, behaviour, attitudes, dietary habits, access to health-related information
and improvement of health literacy and education at community level. Studies suggest that a
community participation approach suited to the socioeconomic setting has been effective in
improving health-related behaviour and promoting health in Japan.

Infrastructure and Supplies

Municipal governments, health centres and urban communities play a major role in
implementing health promotion activities.

Knowledge and Information

An annual National Health and Nutrition Survey is used to systematically and continuously
monitor the progress of Healthy Japan 21 against numerical targets.

This is conducted every November by the Ministry of Health, Labour and Welfare. 300
survey districts are randomly selected through Japan, each district with approximately 30
households. All household members aged >1 year are invited to participate. Public health
centres of local governments are responsible for conducting the survey.

International CVD Prevention Case Study Report Page | 113

REFERENCES

 Bayarsaikhan D. Financing health promotion in Japan and Mongolia. Bulletin of the

World Health Organization 2008. Available from
http://www.who.int/bulletin/volumes/86/11/08-052126/en/ (Accessed February 2018)
 Health Japan 21 (the second term). Analysis and assessment project. Available from
http://www.mhlw.go.jp/seisakunitsuite/bunya/kenkou_iryou/kenkou/kenkounippon21/e
n/kenkounippon21/data01.html (Accessed February 2018)
 Nakao YM, Miyamoto Y, Ueshima K ,Nakao K, Nakai M, Nishimura K, et al. (2018)
Effectiveness of nationwide screening and lifestyle intervention for abdominal obesity
and cardiometabolic risks in Japan: The metabolic syndrome and comprehensive
lifestyle intervention study on nationwide database in Japan (MetSACTION-J study).
PLoS ONE 13(1): e0190862.https://doi.org/10.1371/journal.pone.0190862
 Nishi N. The 2nd Health Japan 21: goals and challenges. The FASEB Journal, April
2014, Abstract number 632.19
 Nishi N. Monitoring obesity trends in Health Japan 21. J Nutr Sci Vitaminol 2015, 61:
S17-S19
 Population of Japan. Available from http://www.worldometers.info/world-
population/japan-population/ (Accessed February 2018)
 Sakurai H. Healthy Japan 21. Journal of the Japan Medical Association 2003, 46(2):
47-49
 Udagawa K. Miyoshi M. Yoshiike N. Mid-term evaluation of ‘Health Japan 21’: focus
area for the nutrition and diet. Asia Pacific Journal of Clinical Nutrition 2008, 17 (S2):
445-452

International CVD Prevention Case Study Report Page | 114

Appendix 9: Franklin County CVD Risk Reduction

FRANKLIN COUNTY CARDIOVASCULAR HEALTH

PROGRAM (CVD risk reduction)
A CASE STUDY
PROGRAMME AT A GLANCE
Franklin County is a low income rural community in Maine,
USA. An integrated, community-wide comprehensive
cardiovascular risk reduction programme was started in 1970
with a 40-year follow-up assessing the impact of risk factor
improvements on reductions in morbidity and mortality.
The programme aimed to focus public, individual and health
professional attention on the importance of long-term risk
factor detection and control.
 In the 1970’s the programme emphasised the
detection and control of hypertension. Volunteer
nurses and trained community volunteers ran
screening, education and follow-up clinics in
community centres KEY TAKEAWAYS
 Volunteer citizen and professional task forces initiated,
promoted and staffed diverse projects promoting  A community initiative
healthy eating focusing on long-term
 The programme promoted various initiatives to risk factor detection
increase physical activity and improve access to and control
facilities
 In the 1980’s the programme emphasised the  Multifaceted
detection and control of hyperlipidaemia using the programme that
same community-outreach model used for adapted over time
hypertension
 Between 1988 and 2011 a number of initiatives  Collaboration between
promoted smoking cessation. These were run by health care
teachers, volunteer health professionals and high professionals and
school students community volunteers
 From 2000 nurses were located in medical practices to
facilitate the care of complex patients  Improved health care
access and integrated
 The programme developed relationships with local
clinical care with
media, with regular programme updates and features
population-wide
on health topics
prevention programmes
Health promotion projects later combined into a hospital-
supported Healthy Community Coalition which served as the
policy, co-ordinating and goal-setting body for the area’s
health education, promotion and prevention activities.
Volunteer citizens and professionals formed regional task
forces.
The programme is no longer operational, but some of the
interventions have been continued by the local Healthy
Community Coalition and the local hospital’s network of
primary and speciality medical practices.

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TARGET POPULATION PROGRAMME EXPERIENCES
In 1970 the population of Franklin County During the years when regional businesses
was 22,444, rising to 30,768 in 2010. In the (often paper and wood mills) thrived,
first four years (1970 to 1974) of the employers paid for screening, follow-up
programme about 50% of the adult and coaching services for their employees
population had community based blood and helped institute effective non-smoking
pressure checks. policies. When the mills were sold to more
distant owners, there was less cooperation
with the programme.
BENEFITS AND OUTCOMES
 In Franklin County (part of the US The programme responded to changing
state of Maine) mortality rates (age demographics and financial support by
and income adjusted) decreased taking the service to the people. For
below Maine rates during 1970 to example, senior citizens initially had
2010, with the greatest differences access to free grant-supported buses to
coinciding with the peak attend community blood pressure clinics.
programme activities When this transport became less available,
the programme took the service to seniors’
 From 1994-2006 Franklin County’s group meetings. When attendance at these
observed hospitalisation rate was meetings diminished, the programme used
significantly lower than predicted by a donor-sponsored mobile van that took
household income (observed vs services to a wide variety of locations
expected difference -17 discharges including shopping centres. This van
per 1,000 population) provided risk factor screening, referral and
coaching.
 The lower than expected
hospitalisation rates were
associated with $5,450,362
(£3,919,300) reductions in total in
and out of area hospital charges for
Franklin County residents per year

 The proportion of people with

treated and controlled hypertension
improved from 1974/75 to 1977/8
(an absolute increase of 24.7%)

 The proportion of people with

treated and controlled cholesterol
levels improved from 1986 to 2009
(an absolute increase of 28.5%).
People with more programme visits
had better control

 Smoking quit rates (ever smokers

who report they have quit) improved
from 48.5% in 1994-5 to 69.5% in
2006-10, with Franklin County quit
rates significantly higher than those
seen in Maine and the US

International CVD Prevention Case Study Report Page | 116

THE DETAIL
Context
An integrated, community-wide comprehensive cardiovascular risk reduction programme
which focused public, individual and health professional attention on the importance of long-
term risk factor detection and control. The programme is no longer operational, but some of
the interventions have been continued by the local Healthy Community Coalition and the
local hospital’s network of primary and speciality medical practices.

Goals, Values and Principles

The Franklin Cardiovascular Health Program was a community-wide prevention programme
targeting cardiovascular risk factors. The programme strategies included:

 Using evidence-based targets, interventions and standard operating procedures

 Measureable and monitored objectives
 Lay and professional leadership
 Primary care clinician and community participation in programme design, implementation
and evaluation
 Co-ordination with and supplementation of medical practices
 Risk factor screening, referral and follow-up with education and individual health
coaching predominantly by a large cadre of volunteer local nurses in multiple community,
school, workplaceand health care settings
 Patient, physician and health coach collaboration, including practice-based nurse care
management
 Monitoring and tracking systems created by the programme

Population
At the start of the programme in 1970, Franklin County Maine was a rural, low income
population of 22,444. In 1990-92 the population was 29,008 and in 2010 the population was
30,768. The population was predominately white. The residents become older and poorer
over the 40 years follow-up, but the ratio of population to primary care physicians improved.
All adults were eligible to participate in the programme.

The 15 other counties in Maine were used as comparators. The population of Maine was
992,048 in 1970, 1,227,928 in 1990-2 and 1,328,361 in 2010.

Service Delivery
The programme started in 1970 and emphasised education and detection using a
community-based clinic model with nurses and trained community volunteers sent into town
halls, churches, schools, grocery stores, restaurants, pharmacies, dental and medical offices
and workplaces:

 Nurses reviewed personal and family history, symptoms, medications and lifestyle and
measured weight, blood pressure and non-fasting serum cholesterol
 Each encounter ended with personal counselling
 People with uncontrolled health conditions were referred to physicians for treatment
 Ongoing results of patient monitoring were sent to the patient’s physician and entered
into the programme database

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 People were encouraged to return for monitoring, counselling and periodic rescreening
and physicians often referred patients to the programme for interval monitoring between
physician visits

Programme elements
 Hypertension: In the 1970’s the programme emphasised the detection and control of
hypertension with at least monthly clinics in each county town. More than 200 health
coaches and volunteer nurses provided multifactorial, integrated cardiovascular risk
factor education, screening, referral and follow-up of all adults in age groups in diverse
settings. There was active follow-up with patients and primary care physicians by mail,
telephone and home visits to improve tracking and control
 Healthy eating: From the outset, the programme promoted healthy eating. Volunteer
citizen and professional task forces initiated, promoted and staffed diverse projects
including community-wide heart healthy menu campaigns involving restaurants, schools
and grocery stores, nutritionist-guided healthy grocery tours and consultations with
school food services to serve heart-healthy meals
 Physical activity: From the outset, the programme promoted physical activity. The local
university added a community health education department and, aided by a community
fund drive, built a health and fitness centre in 1992 with the area’s only indoor pool, open
to students and community residents. Programme staff helped open school facilities for
indoor adult walking, make outdoor recreation areas smoke-free, produced and
distributed brochures on local, year-round fitness opportunities and mapped safe walking
routes
 Hyperlipidaemia: In 1986 a programme was added to detect and control
hyperlipidaemia. This used the same community outreach model as the hypertension
programme, using three person teams of patient, clinician and nurse. In 1986,
programme nurses also began risk factor coaching in selected physician practices
 Smoking: In 1988, a programme was added to minimise tobacco use with a number of
initiatives between 1988 and 2011. Teachers and 50 volunteer health professionals
collaborated in developing and delivering in-class tobacco-related curriculum. State-wide
and national tobacco guidelines and initiatives were adopted locally e.g. adult, youth and
clinician education, community organisation and advocacy, public policy change (i.e.
smoke-free areas) and individual and group intervention. Programme staff, together with
motivated high school students, conducted tobacco sales ‘sting’ interventions on under-
age tobacco sales, with education and follow-up of all regional tobacco product sources
 Complex patients: In 2000, a programme was added to co-manage diabetes in medical
practices. This was a collaborative nurse care management programme facilitating care
for complex patients with lipid disorders, diabetes and/or heart failure. The programme
was later integrated with all hospital-affiliated primary care physician practices

The programme responded to changing demographics and financial support by taking the
service to people. For example, senior citizens initially had access to free grant-supported
buses to attend community blood pressure clinics. When this transport became less
available, the programme took the service to seniors’ group meetings. When attendance at
these meetings diminished the programme used a donor-sponsored mobile van that took
services to a wide variety of locations including shopping centres. This van provided risk
factor screening, referral and coaching.

International CVD Prevention Case Study Report Page | 118

The programme developed relationships with local radio and newspapers. Early in the
programme a local station broadcast weekly live reports with competitive tallying of the
number of blood pressure checks done in towns and workplaces. For decades the radio
station hosted interviews with programme staff on health topics.

Outcomes
Mortality
 Franklin County age and income adjusted mortality rates decreased below Maine
mortality rates during 1970 to 2010, with the greatest differences coinciding with peak
programme activities
 From 1970-89 Franklin County mortality rates were the lowest in Maine (observed vs
expected difference -60.4 deaths/100,000; 95%CI -97.9 to -22.8, p<0.01))
 From 1990-2010 Franklin County’s household income decreased relative to other Maine
counties but they still had significantly lower mortality than predicted by income
(observed vs expected difference -41.6 deaths/ 100,000; 95%CI -77.3 to -5.8, p=0.005)

Figure 1: Age adjusted total and heart disease death rates for Franklin county and
Maine (1960 to 1994) with Franklin program phases (Record et al 2000)

HBP, Programme phase detecting high blood pressure

CHOL, Programme phase detecting high blood pressure and high cholesterol
RHA, Rural Health Associates – not for profit health corporation with federal funding established

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Morbidity
Maine hospitalisation rates are strongly associated with household income. From 1994-2006
Franklin County’s observed hospitalisation rate was significantly lower than predicted by
household income (observed vs expected difference -17 discharges per 1,000 population;
95%CI -20.1 to -13.9, p<0.01).

Hypertension
The proportion of people with treated and controlled hypertension increased from 18.3% in
1974/5, to 43.0% in 1977/8; an absolute increase of 24.7%; 95%CI 21.6% to 27.7%, p<0.01.

Hyperlipidaemia
The proportion of people with treated and controlled cholesterol levels improved from 0.4%
in 1986 to 28.9% in 2009; an absolute increase of 28.5%; 95%CI 25.3% to 31.6%, p<0.01.

From 1986 to 2010 people with more visits were more likely to have treatment for high
cholesterol that resulted in reaching the recommended levels.

Table 1: Visits with programme staff

Number of encounters with Proportion of patients with treated high
programme staff cholesterol at target level
1 12.5%
2 16.6%
3-4 23.1%
5-8 25.0%
9-16 32.2%
<16 38.5%

Smoking
 Smoking quit rates (ever smokers who reported they had quit) improved from 48.5% in
1994/5 to 69.5% in 2006-10
 Quit rates were significantly higher for Franklin County compared to the rest of Maine
from 1996-2000 (observed vs expected difference 11.3%; 95%CI 5.5% to 17.7%,
p<0.01)
 Quit rates were significantly higher for Franklin County compared to the US

Table 2: Quit rates in Franklin County compared to the US

Time period Observed vs expected
difference
1996-2000 17.7% (95%CI 12.4% to 23.0%)
2001-2005 7.7% (95%CI 1.6% to 13.9%)
2006-2010 10.2% (95%CI 6.6% to 13.7%)

Participation rates
 Encounters with programme staff averaged 5,000 per year from 1974 to 1994 and 3,000
per year afterwards
 There were over 150,000 encounters by 2010; an average of more than 5 encounters
per resident

Leadership and Governance

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Local community groups identified CVD prevention as a priority in the late 1960’s and a new
Community Action Agency, a new non-profit medical and dental group practice (Rural Health
Associates (RHA), and later the community’s hospital, initiated and coordinated their efforts
to reduce cardiovascular risk.

In 1974, the RHA, with hospital medical staff sponsorship, established the community-wide
Franklin Cardiovascular Health Program. Leadership was provided by a nurse manager,
medical director and diverse advisory groups.

Health promotion projects later combined into a hospital-supported Healthy Community

Coalition which served as the policy, co-ordinating and goal-setting body for the area’s
health education, promotion and prevention activities. Volunteer citizens and professionals
formed regional task forces.

Over time, many local public and non-profit organisations collaborated on various
components of community efforts. Participants included the hospital, local businesses,
schools, and the University of Maine, which developed a health education degree
programme and trained local Community Action Agency outreach workers.

Continuous quality improvement became the standard operating procedure for regional risk
factor identification and management at individual, population and programme levels. The
programme promoted adherence to national guidelines and guideline based information
systems.

Finances
Funding came from grants (averaging $20,000 annually), client donations and modest fees
for services. Annual budgets averaged $50,000 during 1986-1994, excluding volunteer
efforts and in-kind contributions.

Federal support from 1972 to the mid-1980s came from the Office of Economic Opportunity
and the Rural Health Care Service Outreach grant programme. The programme received
multiple small grants of $10,000 to $80,000, mostly during the initial 20 years, from the
Federal Health Underserved Rural Area grant program, the Bingham Program, the Regional
Medical Program, Maine Bureau of Health, Maine Department of Human Services grants,
Western Maine Community Partnership, the Healthy Communities Coalition, Franklin
Memorial Hospital and the United Way. Federal grants also funded planning and
implementation of a comprehensive capitated health insurance plan for 3,000 indigent
residents.

During the years when regional businesses (often paper and wood mills) thrived, employers
paid for screening, follow-up and coaching services for their employees and helped institute
effective non-smoking policies. When the mills were sold to more distant owners there was
less cooperation with the programme.

Costs
The lower than expected hospitalisation rates were associated with $5,450,362 (£3,919,300)
reductions in total in-and out of area hospital charges for Franklin County residents per year.

Human Resources

International CVD Prevention Case Study Report Page | 121

The programme initiatives were mostly delivered by volunteer nurses and local citizens.
There was also involvement from primary care and the local hospital. Health-coaching was
provided by nurses, health educators and other health professionals and trained lay
volunteers.

Infrastructure and Supplies

The programme sought to integrate current and new clinical and community resources.
Interventions were delivered in a variety of community settings. A health van was used for
screening, education and coaching services in schools, workplaces and health care and
other community settings.

Knowledge and Information

Training
The programme used trained outreach workers, with the local university providing the
training.

Data
Medical record systems provided aggregated data from 1974 to 2009 on screening and
follow-up encounters, demographics, behavioural risk factors and hypertension and
cholesterol control. Additional data was available from routinely collected sources such as
census and local and national disease control centres.

Patients and health-care workers received personalised scorecards to encourage attainment

of personalised goals and to find ‘lost’ at-risk patients and provide performance feedback to
patients, coaches, clinicians, workplaces, practices and other organisations.

REFERENCES
 Record NB. Onion DK. Prior RE. Dixon DC. Record SS. Fowler FL. Cayer GR. Amos
CI. Pearson TA. Community-wide cardiovascular disease prevention programs and
health outcomes in a rural community, 1970-2010. JAMA 2015, 313(2): 147-155
 Record NB. Harris DE. Record SS. Gilbert-Arcari J. DeSisto M. Bunnell S. Mortality
impact of an integrated community cardiovascular health program. Am. J Prev Med
2000, 19(1): 30-38

International CVD Prevention Case Study Report Page | 122

Appendix 10: USA HONU Project

Hearts Beat Back:–the Health of New Ulm

(HONU) project
A CASE STUDY

PROGRAMME AT A GLANCE
New Ulm is a small community of 17,000 people. Local
health organisations were keen to track the cardiovascular
health of the population before and during the
implementation of community wide interventions. The Health
of New Ulm (HONU) project implemented individual, family
and community level interventions in order to influence KEY TAKE AWAYS
behaviour and reduce modifiable cardiovascular disease
(CVD) risk factors. HONU gathered cardiovascular risk data Long term whole
either from electronic records or from community based CVD population approach to
risk assessments held 3 times a year in New Ulm. prevention
 People at risk of CVD or with pre-diabetes were
assigned a health coach to support lifestyle change The project worked with
 Families were invited to come together once a month individuals, families,
and do physical activity and cook together and take workplaces, food
part in taste testing outlets and local
government for
 HONU worked with employers to support them to
multifaceted approach
offer health and wellness activities in the workplace
to prevention
 A systematic method was used to assess how
nutritionally healthy all food outlets were and
 Mid way through the10
supported a shift to more healthy options including
year funding period
smaller portion sizes
(2009 to 2019) a
 HONU implemented community health challenges sustainable system was
around diet and activity set up so the
 The project worked with local government on community could
integrating a health approach when planning continue the work once
changes to the built environment funding had ended
 Safe walking and cycling routes to school and other
school based activities were promoted to parents and  Consistent well
children organised
communications and a
Part way through the programme funding period, plans for
strong leadership team
ongoing sustainability were put in place to ensure from all sectors of the
continuation of the multifaceted approach. community were key
elements to success of
the programme

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TARGET POPULATION
Community prevention approach applied to The study by Sidebottom et al (2016)
whole population of 17,000 in New Ulm, shows improvements (p<0.001) in meeting
Minnesota with focused cardiovascular blood pressure cholesterol and
disease assessment and tracking for those triglycerides recommended levels. There
aged 40-79. were also improvements in the proportion
of people on recommended levels of blood
pressure and, lipid medications and mean
BENEFITS AND OUTCOMES reduction in CVD risk score. Other
outcomes include an increase in CVD risk
Outcomes of a study assessing population-
awareness and increased participation of
level CVD risk factors over a 6-year time
members of the community in a range of
frame before and during project
initiatives focused on increasing physical
implementation are outlined in Table 1
activity, improving diet and reducing
Table 1: Change in CVD risk factors with tobacco smoking.
the Hearts beat back HONU project
(Sidebottom et al 2016) CHALLENGES AND
2008- 2010- 2012- SOLUTIONS
9 11 13
Blood pressure 79.3% 82.3% 86.4% The programme began with funded
at goal* researchers dedicated to working with
On blood 41.8% 43.5% 44.0% particular sectors of the community such
pressure as schools, health services, employers and
medication* food outlets. This funding was available for
Low-density 68.9% 72.3% 71.1% 10 years and the community is now in the
lipoprotein at process of taking on the full scope of the
goal* prevention programme.
High-density 63.8% 59.0% 58.0%
lipoprotein at This is a long term approach which needs
goal to be sustained and supported by all
Cholesterol at 59.2% 64.2% 64.1% sectors of the community in order for a
goal* reduction in CVD risk factors to continue.
Triglycerides at 66.3% 68.7% 70.2%
goal* The New Ulm community is relatively small
On lipid 25.3% 27.7% 29.1% and it is not clear whether if implemented
medication* in a larger more varied population similar
Not obese 56.0% 55.5% 55.1% reductions in CVD risk would be achieved.
Fasting glucose 46.9% 49.7% 48.2% This may however be an approach useful
at goalǂ to more rural towns.
On aspirin 29.3% 33.5% 36.0%
medication*
Smoking 11.3% 12.6% 13.6%
Mean (±SD) 12.1± 11.6±0. 11.5±0.
ASCVD 10-year 0.2 2 2
risk score*
ASCVD 10-year 27.8% 28.9% 27.5%
risk score
<7.5%
*Change between 2008/9 and 2012/13 p<0.001
ǂ
Change between 2008/9 and 2012/13 p=0.023
ASCVD – atherosclerotic cardiovascular disease 10 year risk
score

International CVD Prevention Case Study Report Page | 124

THE DETAIL
Context
The focus is on reducing heart attacks and modifiable CVD risk factors through prevention.

Goals, Values and Principles

The project was developed to address all levels of the social-ecological model with a strong
focus on sustainability following the funding period. Interventions were developed to fill gaps
where current intervention options did not exist and to align with recently identified evidence
based strategies. Where existing interventions did exist, such a smoking cessation, these
were promoted. This project started in 2009 with a 10-year timeframe and is currently
ongoing. It will continue to be run by the community from 2019.

Population
The health promotion campaign was targeted at the rural Minnesota communities of New
Ulm (population 13,500), Springfield (population 2,215) and Sleepy Eye (population 3,600).

The priority population is described as adults aged 40 to 79 living in New Ulm, which has a
total population of 16,759 and 7,855 residents aged 40 to 79 years. This population is 98%
white and insurance levels are high (an estimated 8.7% residents <65 years lack insurance).

The 2009 CVD risk assessment programme was free to adults who resided or worked in the
target community of New Ulm, which had a working age population of about 10,000.

Service Delivery
Between 2009 and 2013 a range of interventions were delivered.

Community Interventions
 Heart Health Screenings: Free to all adults and conducted in 2009 (5,221 screened)
and 2011 (3,215 screened). Participant recruitment for the 2009 screening programme
was through media adverts, direct mail and email, physician referral, website, social
media and announcements by employers and community groups. Screening events
were held at community and workplace locations. Screening involved a 30 minute visit
where participants completed a health survey and had anthropometric (e.g. BMI) and
blood biomarkers collected. Participants received a CVD risk report, including
information on lifestyle risk factors and guidance for medical follow-up as required.
Participants also received health coaching on creating goals for lifestyle risk factors and
were referred to available community or programme-specific resources to help achieve
those goals
 Community Health Summits: Annual community-wide events focused on lifestyle
changes with national motivational speakers. Attendance ranged from 250 to 700 per
year
 Three formal run/ walk events per year: 5 and 10 km distances with participation
ranging from 150 to 600 per event
 Six Community Health Challenges: Using broad annual campaign themes varying in
duration from 6-8 weeks to 12 months. These encouraged small manageable changes
related to physical activity, healthy eating, weight management and stress management.
Enrolment ranged from 539 to 2,236

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 General Education: Cooking classes, grocery store tours, smoking cessation classes
and presentations on a variety of topics. The ‘What’s Cooking New Ulm TV show’ was
presented on a local cable access channel seven times per week (>100 new episodes
produced between 2010 and 2013)
 Small Community Events: Volunteer leaders were trained to promote opportunities for
increased physical activity and health events e.g. physical activity classes, walking
clubs, healthy potluck or dance-a-thon between 2010 and 2011
 Food Environment Improvements: Working with local restaurants, grocery stores and
convenience stores to increase the availability, identification and selection of healthier
options. A Farmers Market Promotion Programme (2012-13) included the distribution of
educational materials and cooking demonstrations. Restaurant initiatives included
assessment using the Nutrition Environment Measures Survey; gold, silver and bronze
achievement levels based on the number of healthy eating practices offered (e.g. more
fruit and vegetables, fewer calories, healthier fats, whole grain options); point-of-decision
prompts e.g. in menus.
o 18 participating restaurants in 2014 (up from 9 in 2011)
o Restaurants report healthy items are easy to make and profitable
o 67% customer awareness of restaurant programme in 2012
o 80% agreed healthy choices in restaurants are easy to identify (up from 76%)
o New food co-op opened
o Farmers markets often closed early due to produce sold out
 Social marketing campaign: An 8-month (2012-13) community-wide social marketing
campaign SWAP IT to DROP IT focused on 100 calorie food and beverage swaps for
weight management. This included simple visual messages, mass media, partnerships
and point-of-decision messages at shops, restaurants and local workplaces and 1-hour
educational tour by registered dieticians at grocery stores with experiential food tasting
opportunities. At the end of this period:
o 70% of adults recognised the ‘SWAP IT to DROP IT’ logo
o 85% swapped unhealthier items for healthier items
o 92% were confident they could make healthier food and beverage choices
o Males particularly showed increases in perceptions of healthy foods availability and
ability to identify healthier choices
o 95% grocery tour participants were referred by a clinical dietician
 Media: Annual communications plan to strategically blanket the community with CVD
prevention messages and promote other programme initiatives. Included press releases,
cable access advertising, radio promotions, billboards, newspaper adverts and articles
and direct mail. This resulted in:
o 94% of adults in the New Ulm community were aware of the project after the first
year
o 49% of adults heard about the project from their employer or co-worker
 Social Media: Facebook and Twitter strategies. Monthly project newsletter distributed
online and in the local newspaper sharing success stories, promoting healthier lifestyles
and highlighting key activities

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Health care Interventions
 HeartBeat Connections: free phone coaching programme targeting individual patients
at high cardio-metabolic risk with the goal of improving use of preventative medications
and reducing lifestyle related risks. People invited to participate through electronic health
record data or referral. Talk via phone for 15-20 minutes with a professional health
coach (registered dietician or registered nurse), typically once a month. Served 1,022
patients in 2010 to 2013. 1 in 3 eligible people engaged with programme
o 200% increase in percentage of patients eating 5+ daily servings of fruits and
vegetables
o 50% decrease in smoking
o 30% increase people meeting recommended level of 150 minutes physical
activity/week
o 70% improved cholesterol
o 95% would recommend phone coaching
o 94% medication adherence to cholesterol medication
 Heart & Vascular Prevention Clinic: Staffed by a nurse practitioner with specialised
lipid knowledge for referred individuals at high risk of heart disease as well as those with
existing heart or vascular disease who need more intensive clinical management.
Available to all people served by the New Ulm Medical Center
 Weight Management Phone Coaching: For individuals with a BMI ≥30 kg/m2 who were
referred by their primary care provider or who were taking part in the LOSE IT to WIN IT
community health challenge. Focused on behavioural strategies such as tracking food
and activity, regular self-weighing, goal-setting and relapse prevention techniques.
Served 235 patients in 2013
 11 Grand Rounds events for physicians and midlevel providers: Raising awareness
about CVD risk reduction, preventative treatment therapies and information about the
project. >90% local health professionals attended at least 1 session with most attending
≥4 sessions.

Workplace Interventions
 Workplace Assessments: Assessment of wellness policies and environment
completed by 46 businesses. Recommendations made e.g. workplace smoking and
nutrition policies.
o 89% employers now promote community programmes and resources for health –
prefer community programmes to workplace programmes
o 72 workplaces engaged in LOSE IT to WIN IT with 1,500 participants
o 116 employers now engaged in some level of wellness programme (previously in
2009 only 5 of largest 100 employers had a wellness programme)
o 5,703 participants in workplace programmes through to December 2013
 Free Heart Health Screenings conducted at workplaces: Aggregate reports given to
participating workplaces showing prevalence of risk factors among employees and
providing recommendations for wellness programmes targeting those risk factors
 Workplace Behavioural Change Programmes: Short (6-8 week) and long (12 month)
behaviour change programmes focused on weight loss, nutrition, self-care and exercise.
14 programmes implemented at 95 workplaces from 2009 to 2013 with 4,879 employees
participating. 24 educational presentations with 1,287 employees at 16 companies and
freedom from smoking classes conducted at 2 workplaces

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 Business leader engagement and education: Annual employer summits with
motivational speakers, attended by 23-35 companies in 5 years. 7 educational events
offered through the New Ulm Area Chamber of Commerce

Additional Interventions described

 SWAP IT to ROCK IT campaign with schools and sports organisations: Aimed to
make healthier food stalls available at sporting events e.g. availability of healthier
options such as fresh fruit, whole grain bread, water, granola bars; stealth improvements
e.g. pizza with lower calories or popcorn made with trans-free fat oil; pricing incentives to
encourage selection of healthier items; life-size photos of coaches and players
promoting campaign messages; strategic promotions at selected events and default
modifications such as water rather than soda in combo meals
o Participating organisations made a profit or broke-even from the outset
o Fruit options sold out at local basketball event
o Healthier pizzas cut into 10 rather than 8 pieces promoting fewer calories per serving
o Positive reviews
 Food explorers programme: Integrating nutrition into the core school’s curriculum in
collaboration with school principals, teachers, food service and other school leaders;
connected classroom, cafeteria and home; trained teachers and parent volunteers to
deliver Food Explorers Programme; taught 1,100 kindergarten and 1st grade students to
cook in the classroom using parents and volunteers
o Increased preference for fruits and vegetables among kids
o Kids more likely to try new foods at home and school
o More cooking together at home
o 100% teachers and food service managers agree programme would build support for
school wellness among students, parents and teachers
o 100% of teachers and parent volunteers desire to do program again
 Complete Streets: Aim to create more opportunities for people to safely walk and bike
in the community. Engaged community leaders in new Coalition for ‘Active, Safe and
Healthy Streets’; national planning and transportation experts toured the community and
made safety improvement recommendations; coalition teams created ‘Safe Routes to
School’, and town bike trail connections were revitalised.
o City Council incorporated improvements to make streets near school safer,
incorporated into already planned resurfacing project
o Street redesign to eliminate parking on residential side of street, add bike lanes and
provide pedestrian crossings 20 mph speed limits

Outcomes
Outcomes are reported in three published analyses for sub-groups of the population.

Study assessing population-level CVD risk factors over a 6-year time frame before and
during project implementation (Sidebottom et al 2016)
Electronic health record data was used to assess changes in CVD risk factors for 7,855
people aged 40-79 at baseline (2008-09) and 2 follow-up periods (2010-11 and 2012-13).
Mean (standard deviation) age ranged from 56.4 (10.5) years at baseline to 57.6 (10.4) at
last follow-up and 53% were female.

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Table 2: CVD risk factors over a 6-year time frame before and during project
implementation
2008-9 2010-11 2012-13
Blood pressure at target(<140/90 Hg)* 79.3% 82.3% 86.4%
On blood pressure medication* 41.8% 43.5% 44.0%
Low-density lipoprotein at target 68.9% 72.3% 71.1%
(<130mg/dL)*
High-density lipoprotein at target 63.8% 59.0% 58.0%
(40+mg/dL men; 50+mg/dL women)
Cholesterol at target(<200mg/dL)* 59.2% 64.2% 64.1%
Triglycerides at target (<150mg/dL)* 66.3% 68.7% 70.2%
On lipid medication* 25.3% 27.7% 29.1%
Not obese (BMI <30kg/m2) 56.0% 55.5% 55.1%
Fasting glucose at target(<100mg/dL)ǂ 46.9% 49.7% 48.2%
On aspirin medication* 29.3% 33.5% 36.0%
Smoking 11.3% 12.6% 13.6%
Mean (±SD) ASCVD 10-year risk score* 12.1±0.2 11.6±0.2 11.5±0.2
ASCVD 10-year risk score <7.5% 27.8% 28.9% 27.5%
*Change between 2008/9 and 2012/13 p<0.001
ǂ
Change between 2008/9 and 2012/13 p=0.023
* ASCVD – atherosclerotic cardiovascular disease 10 year risk score

The number of non-obese adults and the number achieving the high-density lipoprotein goal
did not significantly improve. The number of smokers increased from 11.3% to 13.6%. The
mean atherosclerotic (AS) CVD score improved but the number considered at low risk
(<7.5%) for a cardiovascular event did not significantly improve.

These results are also presented separately for men and women. Significant differences by
gender included greater increase in lipid use among women (improvement of 5.5% vs 1.8%
for men, p=0.001) and greater increase of men with fasting glucose at target (improvement
of 3.6% vs fluctuating scores for women, p=0.024). Women showed a significant
improvement in the proportion with an ASCVD score <7.5% (from 25.2% to 28.7%,
p=0.013). The corresponding improvement in men was not statistically significant.

Significant improvements in mean values for adults who had uncontrolled levels at baseline
were seen for blood pressure, low-density and high density lipoprotein, total cholesterol,
triglycerides, glucose and BMI. The proportion of this sub-group of adults who achieved
targets at follow-up was not reported.

The study authors reported that these improvements in the Heart of New Ulm population
were better than changes seen in national data over a similar time period.

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2-year lifestyle changes and prevention of metabolic syndrome (VanWormer et al 2017)
Analysis of 2 year changes in lifestyle risk factors and incidence of metabolic syndrome for
1,059 people who completed a risk assessment in both 2009 and 2011, were aged 18 to 79
and did not have metabolic syndrome at baseline.

 12% developed metabolic syndrome by 2011

 Optimum Lifestyle Score (OLS) (see below): 29% improved, 57% remained stable; 14%
decreased
 In multivariate analysis:
o 2 year decrease in OLS was associated with greater odds of metabolic syndrome
compared to stable OLS (OR 2.92 95%CI 1.69 to 5.04, p,0.001)
o Risk of metabolic syndrome was significantly associated with older age (OR 1.03
95%CI 1.01 to 1.04, p=0.003); CVD at baseline (OR 3.04 95%CI 1.26 to 7.29,
p=0.013) and diabetes at baseline (OR 5.64 95%CI 2.01 to 15.83, p=0.001)
 In sensitivity analysis, significantly greater odds of metabolic syndrome were significantly
associated with:
o Change of BMI from <30 to ≥30 (OR 7.65 95%CI 3.45 to 17.00, p<0.001)
o Change from eating ≥5 to <5 servings/day fruit and vegetables (OR 3.94 95%CI 1.29
to 12.08, p=0.016
o Change from 0-14 to >14 alcoholic drinks /week (OR 6.22 95%CI 1.06 to 36.67,
p=0.043)

Measures
Metabolic syndrome includes the presence of at least three of: abdominal obesity, high
blood pressure, low HDL cholesterol, high triglycerides and/or high blood glucose.

An Optimal Lifestyle Score was created with participants achieving 2 points (to a maximum
of 10 points) for optimal lifestyle thresholds. These were BMI <30kg/m2, being a non-
smoker, drinking <14 alcohol drinks per week, eating ≥5 servings fruit/vegetables per day
and ≥150 minutes per week of moderately equivalent physical activity. Difference
between2009 and 2011 OLS was classed as greatly improved (increase ≥4 points);
modestly improved (increased by 2 points); stayed the same (reference category);
decreased (decreased by ≥2 points).

2-year outcomes for employed adults (VanWormer et al 2015)

Analysis of the 2-year outcomes of a sub-group of 1,273 employed adults who had a CVD
risk assessment in 2009. This sub-group were 62% female and had a mean ±standard
deviation age of 47.5 ± 10 years). Key findings:

 Overall, adults lost 3.7% (± 11.2) of their work hours due to health reasons in 2011
(2009 figure not reported)
 Significant association between smoking and productivity loss (9.3% for adults who
continued to smoke vs. 2.5% for adults who did not smoke during the 2 year period,
p=0.031)
 No other lifestyle changes were significantly associated with workplace productivity loss
 No figures reported for change from baseline for lifestyle measures

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Measures
Productivity loss: Assessed using the Work Productivity and Activity Impairment
Questionnaire. This captures the percent decrease in total work time over the previous week
as a result of combined absenteeism due to health reasons and is scored from 0% to 100%
with higher scores indicating lower productivity.

Change in lifestyle factors: Assessed using questions on smoking (never, current or former
smokers), alcohol use (drinks per week), fruit/vegetable consumption (servings per day) and
physical activity (minutes per week of moderately equivalent physical activity).

Leadership and Governance

The project is a collaborative partnership between the Minneapolis Heart Institute

Foundation, Allina Health (health care system operating the New Ulm Medical Centre) and
the New Ulm community.

Intervention development was conducted by project staff in collaboration with a community

steering committee with key stakeholders from many sectors of the New Ulm community.
This group provided regular feedback and developed project strategy.

A Clinical Leadership team was formed to drive the health care objectives and included the
hospital president, local medical director, cardiologist medical director and physicians and
midlevel providers. This team met quarterly to discuss project initiatives.

Programmes were tailored to the local culture with the help of the steering committee and
informed by focus group and survey data from target audiences for specific programmes.

In order to ensure sustainability, part way through the funding period the researchers began
putting in place systems to support the continuation of the work across the community. A
main leadership group was formed with 11 sub-groups focused on progressing different
community approaches.

A leadership group of 12 key stakeholders strategically assess health needs and drive the
community priorities. The leadership team comprise representatives from schools, local
health services, large employers, chamber of commerce, local government, grocery stores
and food outlets. There are 11 action teams progressing the different community.
approaches.

Finances
Heart of New Ulm interventions were primarily funded by Allina Health, the health care
system operating the New Ulm Medical Center, with additional funding from government and
foundation grants.

The social marketing campaign ‘Swap It to Drop It’ was grant-funded. The ‘local health
system’ continued funding for dietician-led tours and the local grocery store hired a part-time
dietician.

The Farmers Market Promotion Program was funded by a USDA grant.

Complete Streets was helped by federal grant funding.

In order to ensure sustainability, part way through the funding period the researchers began
putting in place systems to support the self-funding and continuation of the work across the
community.

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Human Resources
A small number of people were funded by the project at the outset, including trained nurses
who could undertake the screening sessions in the community and at workplaces. Health
workers funded by the project also worked with employers to help put new health education
or other activities in place for employees. Researchers funded by the programme undertook
the communications role across all sectors. A dietician worked with food outlets to assess
the nutritional health of the food they offered and develop and implement plans to improve
the healthy options offered.

At the end of the funding period when these externally funded roles disappeared, the
responsibility for these activities was integrated into the leadership team. The team is
formed of representatives working in a range of organisations across the community and
these organisations have committed a member of staff to be part of the team and the roles
and responsibilities are incorporated into their job descriptions.

Infrastructure and Supplies

The thrust of the programme was to put activities and support into existing community and
health settings. Researchers and supplies were funded over a 10 year period. This included
communications and educational materials and equipment for undertaking health screening.

Knowledge and Information

Data collection
Health information was tracked from electronic health records and community health
screening. Resident surveys and assessments of food outlets and health needs
assessments were collated.

The vast majority of the community get medical care from the New Ulm Medical Center,
which facilitated data tracking via electronic health records.

REFERENCES
 Sidebottom AC. Sillah A. Miedema MD. Vock DM. Pereira R. Benson G. Boucher JL.
Knickelbine T. Lindberg R. VanWormer JJ. Changes in cardiovascular risk factors
after 5 years of implementation of a population-based program to reduce
cardiovascular disease: The Heart of New Ulm Project. American Heart Journal
2016, 175: 66-76
 VanWormer JJ. Boucher JL. Sidebottom AC. Sillah A. Knickelbine T. Lifestyle
changes and prevention of metabolic syndrome in the Heart of New Ulm Project.
Preventative Medicine Reports 2017, 6: 242-245
 VanWormer JJ. Boucher JL. Sidebottom AC. Two-year impact of lifestyle changes on
workplace productivity loss in the Heart of New Ulm Project. Occup. Environ Med
2015, 72: 460-462

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Appendix 11: Hypertension Canada
Con
HYPERTENSION CANADA

A CASE STUDY

PROGRAMME AT A GLANCE
Hypertension Canada was formed in 2010 from the merger of
the Canadian Hypertension Society, the Canadian
Hypertension Education Program and Blood Pressure Canada.
Previously, all three organisations had worked independently to
improve hypertension diagnosis and management.
Hypertension Canada focusses on three main areas of activity:
 Research - Building capacity and undertaking
hypertension surveillance
 Education – Improvement of diagnosis and
management through dissemination of guidelines and KEY TAKEAWAYS
recommendations
 Advocacy - Collaboration with stakeholders and  Hypertension Canada
governments to create supportive environments through has worked to improve
improved awareness, prevention, and treatment the diagnosis and
control of hypertension
The main goal for Hypertension Canada is to ensure that across Canada
Canada continues to be effective in controlling hypertension
within the population. To do this Hypertension Canada is  Canada controls
reducing misdiagnosis by ensuring that all healthcare hypertension in those
professionals in Canada are appropriately trained to diagnose
diagnosed with the
hypertension and follow recommended guidance to mange the condition better than
condition. most other countries.
Hypertension Canada is responsible for a number of the key
elements of hypertension control in Canada including:  Hypertension Canada’s
work is based around
 The production of annual evidence based guidelines on the creation of annually
hypertension treatment and management updated guidelines and
 The establishment of a national healthcare public and recommendations
professional education programme
 Encouraging the development of community  Implementation of the
interventions and programmes guidelines is supported
 Monitoring the progress of hypertension treatment and by an education
prevention initiatives in Canada. programme targeted at
In addition, Hypertension Canada and its predecessor health professionals
organisations have also worked with partners to achieve: and the public

 The establishment of the nationally funded position of

Canadian Institute of Health Research (CIHR)
Hypertension Prevention and Control Chair in 2006 and
 The publication of the Pan Canadian Hypertension
Framework in 2011, a national hypertension strategy.

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TARGET POPULATION Hypertension Canada suggests that key
success factors have been:
The efforts of Hypertension Canada are
aimed at all Canadians.  Improving the acceptability of the
Hypertension Canada identified key clinical guidelines to health care
opinion leaders and educators and professionals by ensuring they are
specifically targeted them and sought to independent and transparently
directly involve them in the delivery of the developed.
programme. Hypertension Canada created  Building coalitions and partnerships
a network of educators across Canada in involving government and non-
pharmacy and medical schools and government organisations and the
networked them together with use of public.
technology to facilitate the dissemination of  Having clear and consistent
their guidelines. messaging from multiple sources
has been important for engaging
BENEFITS AND OUTCOMES patients and the public.
The main outcome of the work of
Hypertension Canada’s and its previous
incarnations has been an improvement in
the rate of controlled hypertension in those
diagnosed with the condition. The
proportion of Canadians with hypertension
that is treated and controlled increased
from 13.2% in 1986-1992 to 68.1% in
2012/13. The proportion of Canadians with
hypertension receiving appropriate drug
therapy has increased from 35% to 80%.
The proportion of people diagnosed with
hypertension of those estimated to have
the condition in the population increased
from 57% in 1992 to 84.3% in 2013.

The number of antihypertensive

prescriptions issued has increased steadily
since 2007, but prescribing costs have
fallen, primarily due to cheaper generic
medication being available. Mortality rates
amongst Canadians with hypertension
have also reduced.

PROGRAMME EXPERIENCES
Hypertension Canada uses a commercial
database to monitor trends in drug
prescriptions for people with hypertension,
allowing them to monitor increases in
antihypertensive medication prescriptions.

The National Health Measures Survey is

used to obtain data on the diagnosis,
treatment and hypertension and routine
administrative data is also used to monitor
hypertension at a regional level.
THE DETAIL
Context
Historically, in Canada the diagnosis and treatment of hypertension had been left to family
doctors with little or no involvement of secondary care. This approach resulted in only 13%
of patients diagnosed with hypertension having their disease properly controlled in the late
1980’s.

In 1986 a joint federal/provincial committee developed a hypertension prevention and control

strategy. One of the main recommendations from this strategy was to develop a national
coalition of government and non-government organisations to implement measures to
improve hypertension and control across Canada.

The coalition (which became known as Blood Pressure Canada) worked with the Canadian
Hypertension Society to develop a series of guidelines for assessing blood pressure (BP),
improving adherence to lifestyle and pharmacotherapy and home/self-assessment of blood
pressure. The coalition also developed a set of lifestyle recommendations that
systematically assessed and graded evidence and recommendations, as well as provided an
update to pharmacotherapy and diagnosis.

A refreshed national strategy was produced in the 1990’s led by Blood Pressure Canada. In
considering how to operationalise the strategy an enhanced guideline development process
was created, which became known as the Canadian Hypertension Education Program
(CHEP). Over time it became clear that help was needed to implement and evaluate the
impact of the CHEP guidelines and recommendations. This led to the creation of an
Implementation Task Force and subsequently an Outcomes Task Force.

In 2009, a process was developed that merged Blood Pressure Canada, CHEP, and the
Canadian Hypertension Society into a new organisation called Hypertension Canada that
has operated since 2010.

Goals, Values and Principles

Hypertension Canada is a not for profit organisation committed to the prevention and control
of hypertension and its complications.

It cites its mission as being “Advancing health through the prevention and control of high
blood pressure and its complications” and has a vision that “Canadians will have the
healthiest and best managed blood pressure in the world”.

There are a number of key principles that govern how Hypertension Canada operates.

These include:

 Evidence based - ensuring that all their work is evidence based, particularly in
relation to guideline development
 Innovative – Hypertension Canada tries to encourage innovative practice, for
example in supporting single pill combination therapy, which avoids patients having
to take 3 – 4 different pills
 Multi-disciplinary collaborative – the work of Hypertension Canada involves
professionals from many disciplines who collaborate to deliver the different elements
of Hypertension Canada’s work
 Transparency – Hypertension Canada believes their work and guideline
development methodology should be transparent and open to challenge
 Volunteer leadership – initially, the organisation was entirely volunteer-led, but now
there is a small number of paid staff in more managerial/director level roles.

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 However, all the members of the various committees and sub-groups are still
volunteers
 Respectful – in order to foster collaborative working there is a culture of professional
respect across the organisation.

Hypertension Canada strives to ensure that it engages healthcare professionals across all
disciplines to continually build credibility and relevance.

Population
Hypertension Canada’s work is aimed at all Canadians.

Service Delivery
Hypertension Canada use the diagram below to illustrate the key components of their work
programme.

Figure 1: Main components of the work of Hypertension Canada

The work being taken forward by Hypertension Canada to better prevent, diagnose and treat
hypertension in Canada is an ongoing effort.

The interventions currently being provided include:

 The annual publication of evidence based guidelines and updates to previously

published guidelines on hypertension management as part of the Canadian
Hypertension Education Program (CHEP)
 The education of healthcare professionals in hypertension management via an
annual conference, workshops and online Professional Education Program (PEP)
accessed via: https://lowersodium.ca/en/pep-online. Hypertension Canada is
currently reviewing how best to update this programme as some of the content is
starting to become dated
 Raising awareness of hypertension and its risk factors amongst the Canadian public
through healthcare professionals and also by providing patient education materials,
such as the ‘Get Down BP’ mobile phone app

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  Undertaking advocacy to create environments in which the guidelines can be
successfully implemented and Canadians feel empowered to take control of their
health and ensure that government and the public are aware of the importance of
keeping blood pressure under control.

Canadian Hypertension Education Program (CHEP) Guidelines:

A Guidelines Taskforce comprising an unpaid voluntary group of clinical and healthcare

professionals oversees the production of the guidelines. The taskforce currently has 81
members.

The Taskforce has two co-chairs, a GP and a pharmacist. There are 16 sub-groups each
with a Chair and a small number of volunteer members and access to a librarian who does
all of the literature searching. The draft guidelines are reviewed and commented on by a
Central Review Committee which comprises experts in evidence based medicine and clinical
epidemiology. Once the Central Review Committee is happy with the draft guideline it goes
forward for presentation at an annual congress where all 81 members of the Taskforce vote
on whether to adopt the guideline or not, with 70% voting in favour being required for a
guideline to be adopted. After the Congress, a further round of on-line voting takes place, so
that any Taskforce members unable to attend the congress also get the chance to vote and
here a 75% majority is required for the guideline to be adopted.

In terms of implementation, the guideline manuscript is provided to the Education and

Implementation Committee. The members of this committee go through the approved
guidelines and highlight the key messages and the most important points to highlight to
healthcare professionals each year. Historically, the Education and Implementation
Committee has produced a ‘What’s new’ booklet that highlights the most pertinent
information from that year’s new guidelines and updates of existing guidelines. Following
feedback from healthcare professionals, in 2018 a 28 page booklet was produced that walks
healthcare professional through the key information from the guidelines from diagnoses to
treatment and follow up.

There are up to 40 publications a year in medical journals based on Hypertension Canada’s

guideline recommendations.

CHEP Educational Activities:

Key messages from the Canadian Hypertension Education Program (CHEP) aimed a
healthcare professionals have included:

 Know the current blood pressure of all your patients

 Encourage the use of approved devices and proper technique to measure blood
pressure at home
 Assess and manage CV risk in hypertensives including: high dietary sodium
intake, smoking, dyslipidemia, dysglycemia, abdominal obesity, unhealthy eating,
and physical inactivity.
 Sustained lifestyle modification is the cornerstone for the prevention and control
of hypertension and the management of CV disease.
 Treat blood pressure to <140/90 mmHg.
 In people with diabetes target to <130/80 mmHg and more than one drug is
usually required including diuretics to achieve BP targets.

Hypertension Canada has succeeded in getting the importance of diagnosing and treating
hypertension included in the syllabus at a number of medical schools across the country.

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Hypertension Canada works mostly with healthcare professionals, but does also produce
some resources for the public, including a mobile phone app (Get Down BP) and information
about blood pressure and risk factors available on the PEP website. During Blood Pressure
month, Hypertension Canada usually partners with a blood pressure device manufacturer to
run an awareness campaign and encourage people to have their blood pressure checked at
least annually.

Outcomes
Outcomes from Hypertension Canada’s work have been reported in published papers and in
a conference presentation and a webinar prepared for Public Health England.

A published paper detailing the history and development of Hypertension Canada (Shiffrin et
al, 2016) states that the Canadian Hypertension Education Program (CHEP) was associated
with increases in the proportion of diagnosed hypertension cases in Canada (from 57% in
1992 to 84.3% in 2013), the proportion of diagnosed cases receiving drug treatment (35% to
80%) and the control of hypertension (13% to 80%). It was also associated with large
reductions in the rates of death and hospitalisation from cardiovascular disease, acute
myocardial infarction, heart failure and stroke.

A conference presentation produced for a Public Health England conference in 2015

highlights the success of the programme in improving awareness of hypertension amongst
those with the disease and improving control of hypertension amongst diagnosed cases.

Table 1: Trend in hypertension awareness and control

Canada Ontario Canada Canada

(1986-1992) (2006) (2007-2009) (2009-2011)
Treated and 13.2% 65.7% 65.9% 63.9%
controlled
Treated but 21.4% 14.7% 14.0% 15.1%
not
controlled
Aware but 22.4% 5.8% 3.5% 3.8%
not treated
Unaware 43.0% 13.7% 16.6% 17.2%

A published paper provided to SPH by Hypertension Canada (Padwal et al, 2016) about
the epidemiology of hypertension in Canada described a number of trends in aspects of
hypertension diagnosis and treatment.

The paper reported that the proportions of Canadians with hypertension detected and
treated had remained relatively stable since 2007-2009, but the proportion of
hypertension patients with controlled disease has increased from 65.9% in 2007-2009 to
68.1% in 2012/13 (Figure 2). The prevalence of hypertension was also found to have
increased from 19.6% to 22.6% over the same period.

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Figure 2: Trends in hypertension prevalence, proportions diagnosed, treated and with
controlled hypertension, 2007 - 2013

Cycle 1 = 2007-2009

Cycle 2 = 2009-2011

Cycle 3 = 2012-2013

The paper also reported that in the diabetic population for the period 2012/13 the prevalence
of hypertension was 67.1% based on a threshold of 130/80 mm Hg. Of those with
hypertension 60.1% were treated and hypertension was controlled with a further 33.1% were
treated but hypertension was uncontrolled. If a threshold of 140/90 mm Hg was used for the
diagnosis of hypertension in respondents with diabetes, then 88.6% of respondents were
treated and the disease was controlled.

The paper noted that the number of antihypertensive prescriptions has increased steadily
since 2007, but prescribing costs have fallen, primarily due to cheaper generic medication
being available.

Figure 3: Trends in the prescribing of antihypertensive drugs, 2007 to 2014

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The paper stated that analysis of mortality data shows declining death rates in Canada for
both individuals with hypertension and those without hypertension. However, the relative
risk of death for those with hypertension is compared to those without hypertension is
increasing (relative risk 1.2 in 1998 rising to 1.6 in 2010). The authors concluded that this
reflects that fact that control of hypertension is less than 100% in Canada and that
uncontrolled hypertension often clusters with other risk factors such as coronary artery
disease, high cholesterol and low physical activity.

Figure 4: Trends in age-standardised mortality rates and relative risk ratio for those with and
without hypertension, 1998 - 2010

The October 2015 update to the 2011 Pan Canadian Hypertension Strategy written in 2015
detailed the progress made so far in achieving the various targets set within the 2011
strategy to be achieved by 2020. It suggested that based on the current trajectory, most of
the Framework targets are unlikely to be achieved by 2020. Based on survey data from the
Canadian Measurement Survey, there has been little change since 2011 in the prevalence of
hypertension, awareness of hypertension, diagnosis and control rates, suggesting that
preventative interventions have so far been less successful than interventions aimed at
those already diagnosed with hypertension.

Table 2: Progress towards 2020 targets set out in the 2011 Pan-Canadian hypertension
strategy

2007-2009 2010-2011 2012-2013 2020 Target

Hypertension Prevalence 19.6% 21.8% 22.6% 13%
Awareness of condition 83.4% 82.9% 84.3% 95%
Diagnosed with hypertension 8.5% 11.1% 6.6% 40%
with normal BP while not
on antihypertensive drug
treatment a (i.e. lifestyle
control of hypertension)
Appropriate drug therapy 79.9% 79.2% 79.6% 87%
Blood pressure under control 65.9% 64.1% 68.1% 78%

The report makes a number of recommendations to national and regional government to

improve performance against these targets, calling for a national physical activity strategy, a
national healthy food policy and better implementation of the 2010 Sodium Reduction
Strategy and for established and effective community programmes (such as CHAP) to be

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scaled up and sustained as well as new programmes to be developed for deprived and hard
to reach groups.

Leadership and Governance

Hypertension Canada has a volunteer Board of Directors drawn from medical disciplines,
government and business leaders, which includes the CEO, President and the Treasurer.
There are 14 members in total drawn from a wide range of professional backgrounds.

There is a small paid staff of 5 full time equivalent posts, with the majority of Hypertension
Canada’s work being delivered by volunteers on various committees, sub-groups and
taskforces.

The Hypertension Canada Guidelines Committee (HCGC) comprises a multidisciplinary

panel of content and methodological experts, divided into 16 sub-groups, each representing
a distinct area of hypertension. Activities of the HCGC are supported by Hypertension
Canada. The members of the HCGC are unpaid volunteers who contribute their time and
expertise to the annual development and dissemination of the Hypertension Canada
guidelines.

Hypertension Canada’s guideline development process has been externally reviewed and
found to be in accordance with the Appraisal of Guidelines for Research and Education II
(AGREE II) instrument for guideline development.

The organisational structure of Hypertension Canada is shown in Figure 5 below:

Figure 5: Organisational structure of Hypertension Canada

Board of Directors

CEO Operations
Staff Committee

CHEP Standing
Recommendations Committees and
Task Force Task Forces

Finances
Hypertension Canada is a not for profit organisation and receives no government funding.

Funding is provided via sponsorships, from membership fees, from donations and from
sales. The latter relates to the Hypertension Canada’s Blood Pressure Measurement Device
Recommendation Program which allows manufacturers of blood pressure measurement
devices to submit their devices for validation by Hypertension Canada. Hypertension
Canada looks at the evidence base for the device and if it is in line with the evidence, the
manufacturer is allowed to use an approved by Hypertension Canada log in their
advertising/marketing material.

Human Resources

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The programme is delivered by a multidisciplinary team and relies heavily on over 80
volunteers from all parts of Canada. The team includes:

 Primary care physicians

 Medical specialists in cardiology, internal medicine, endocrinology, nephrology,
neurology, paediatrics, maternal-fetal medicine
 Nursing
 Pharmacy
 Dieticians
 Psychologists
 Researchers

From 2000 to 2010 the number of people involved in the work now being taken forward by
Hypertension Canada increased from 20 to about 150.

Infrastructure and Supplies

There is not a very significant manpower infrastructure as Hypertension Canada has only 5
FTE salaried staff. A lot of Hypertension Canada’s work is carried out by volunteers.

Knowledge and Information

Most training is provided to healthcare professionals and is connected with implementation
of the Hypertension Canada clinical guidelines.

The Hypertension Canada Research and Evaluation Committee (formerly the Outcomes
Research Taskforce) conducts surveillance studies on hypertension and reviews existing
Canadian health surveys to identify gaps between current and best practices.

Progress towards the targets included in the 2011 Pan Canadian Hypertension Framework
is monitored via the Canadian Measures Survey and by the Canadian Primary Care Sentinel
Surveillance Network.

REFERENCES
 PHE Conference presentation on work of Hypertension Canada:
 PHE Webinar on work of Hypertension Canada:
 Campbell et al. A Framework for Discussion on How to Improve Prevention,
Management, and Control of Hypertension in Canada. Canadian Journal of
Cardiology 28 262–269. 2012.
 Shiffrin et al. Hypertension in Canada: Past, Present and Future. Annals of Global
Health. Vol 82. No 2. 2016
 Padwal et al. Epidemiology of Hypertension in Canada – An update. Canadian
Journal of Cardiology. 32 687-694. 2016
 Nerenberg et al . Hypertension Canada’s 2018 Guidelines for Diagnosis, Risk
Assessment, Prevention, and Treatment of Hypertension in Adults and Children.
Canadian Journal of Cardiology 34 506e525. 2018
 Hypertension Canada. Hypertension Prevention And Control In Canada: A Strategic
Approach To Save Lives, Improve Quality Of Life And Reduce Health Care Costs,
2015 Update

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Appendix 12: US - Million Hearts

®
MILLION HEARTS INITIATIVE

A CASE STUDY

PROGRAMME AT A GLANCE
In 2012 the Million Hearts initiative was established by the
US Department of Health and Human Services, the Centre
for Disease Control and Prevention (CDC) and Centres for
Medicare and Medicaid (CMS). This national initiative had a
first phase, 5-year goal, of preventing 1 million
cardiovascular events by 2017, and is now in its second
phase, Million Hearts 2022.
Million Hearts works to align CVD prevention efforts across KEY TAKE AWAYS
50 states and 120 partners in the US by focussing on a small
set of evidence-based priorities selected for their impact on  The public, private and
heart disease, stroke and related conditions. non-profit sectors have
Promoting clinical quality improvement such as the been encouraged to
implementation of the ABCS approach to CVD management work together in a
(Aspirin when appropriate, Blood pressure control, coordinated way to
Cholesterol management, and Smoking cessation) and achieve targets and
meaningful use of health tools and technology such as share goals.
electronic records for identifying and monitoring patient
groups are key activities. Community approaches include  The aim to prevent a
introducing policies to eliminate artificial trans-fat intake, million CVD events was
reduce tobacco use and reduce sodium intake. easily understood and
resonated with diverse
Million Hearts 2022 continues these activities but new stakeholders. Focus
emphasis is placed on achieving 70% participation in cardiac on a limited set of
rehabilitation by 2022. Key to achieving these aims are: proven, high-impact
 Health care teams prioritise detection, treatment and interventions helped
control and review data regularly to keep on track partners prioritise their
 Using technology that includes decision support, efforts.
patient portals, registries, and algorithms to find gaps
in care  Million Hearts has been
 Processes around treatment protocols, proactive integrated into nursing
outreach and finding patients with undiagnosed high and inter-professional
BP, cholesterol or tobacco use educational curricula
 Patient and Family Supports – training in home BP and community settings
monitoring, problem solving in medication adherence,
counselling on nutrition, physical activity, tobacco
use, referral to community-based physical activity
programs and cardiac rehabilitation
 Health care professionals and health care
organisations promote activities that reduce the
likelihood of CVD such as increased physical activity,
healthy eating and smoking cessation.
TARGET POPULATION incentive programs rewarded health
care practices for achieving
In its first phase, of Million Hearts the
meaningful use of EHRs. Use of
programme targeted the US population to
EHRs for outpatient care increased
support activities and policies to develop
from 34% in 2011 to 87% in 2015.
healthier habits and environments for
Health information technology has
people in all communities. The second
helped identify more than half a
phase Million Hearts 2022 continues to
million people who may have
develop effective public health strategies
hypertension.
but also identified priority populations
including African Americans, 35-64 year  Innovations in Care Delivery: Health
olds, people who have had a heart attack care systems have been able to
or stroke and people with mental and/or use millions of dollars in public and
substance use disorders. private funds to improve
performance on the ABCS.
BENEFITS AND OUTCOMES
During the first two years of the initiative, it PROGRAMME EXPERIENCES
is estimated that about 115,000
cardiovascular events were prevented,  The strength of the network and its
relative to the number of events in 2011 partnerships are viewed as key to
and 500,000 between 2012 and 2016. the success of Million Hearts.
These events include emergency Organisations apply to be partners
department visits, hospitalizations, and through the Million Hearts website
deaths due to myocardial infarction, stroke, and a range of resources are
heart failure, and related conditions. available providing platforms of
However final numbers will not be available communication and shared
until 2019. The reduction in events cannot learning.
be attributed solely to the initiative, but the  The first phase Million Hearts 2017
reduction is noteworthy because, until informed the strategy of Million
2011, there had been a flattening trend in Hearts 2022, identifying priority
CVD mortality. Outcomes include: populations and additional areas of
focus such as cardiac rehabilitation.
 ABCS measures were widely  There was delayed federal action
adopted with an on overall on guidance to the food industry for
controlled hypertension rate for the voluntarily reduction in sodium in
US of 58% in 2016 up from 53% in processed and commercially
2009/10 prepared food was issued in June
 Controlled hypertension was 2016 which slowed progress.
reported in 80% of hypertensives by  There was delayed federal action
59 hypertension control champions on announcing that partially
covering 13.8 million people hydrogenated oils were not safe so.
 Reduction in smoking: 7 million Policy in place during 2018.
fewer people smoked cigarettes in  Key indicators have been slow to
2015 than in 2011. improve but it is hoped that with a
 Increase of 48.1% to 58.8% raft of guidance, training policies
between 2011 and 2016 of and initiatives now in place there
population covered with will be an acceleration of progress.
comprehensive smoke free law
 Millions of Americans are now
served by health care systems that
recognise or reward performance in
the ABCS e.g. the Million Hearts
Hypertension Control Challenge
 Health Tools and Technology: CMS
Electronic Health Record (EHR)
THE DETAIL
Context
Million Hearts supports community activities and policies that it is hoped will result in
healthier habits and environments for people across the US, such as reducing smoking,
reducing sodium intake and eliminating trans-fat intake. It also focuses on clinical quality
improvements related to ABCS measures(Aspirin when appropriate, Blood pressure control,
Cholesterol management, and Smoking cessation), use of health tools and technology to
detect CVD risk and innovations in care delivery. The engagement of partners and ongoing
collaboration was a key and clear aim of preventing a million events, a message easily
understood by stakeholders. Some interventions are implemented at national level affecting
the whole population, for example, policy change on trans-fats and guidance on sodium
reduction, and others, such as meeting the ABCS, are enacted at local level and are
targeted at those identified as having specific high risk factors.

Goals, Values and Principles

Million Hearts was established by the US Department of Health and Human Services the
Centre for Disease Control and Prevention (CDC) and Centres for Medicare and Medicaid
(CMS) in 2012. This national initiative had a first phase five year goal of preventing 1 million
cardiovascular events by 2017, and is now in its second phase, Million Hearts 2022.

Million Hearts 2022 continues these activities but new emphasis is placed on achieving 70%
participation in cardiac rehabilitation by 2022, and priority populations have been identified.

The program is challenging the clinical health system and the public health community to
increase their collaboration to prevent cardiovascular disease by focusing on the ABCS,
increasing use of health information technology including electronic health records, and
integrating team-based care into everyday practice. Public health helps clinical care by
making the case for effective public policies such as reducing salt and trans-fat in prepared
foods and establishing smoke-free environments to help prevent heart attacks and strokes.

Working with communities, health systems, non-profit organisations, federal agencies, and
private sector partners, the collaborative approach is an important feature of the initiative.
Varda et al (2018) used a social network analysis approach to assess the Million Hearts
network partnerships and identify potential implications for policy and practice. The authors
conclude that the Million Hearts network is unique in its membership at the national level,
agreement on outcomes and information-sharing abilities that require few resources. There
is a decentralized structure with the core team and stakeholders continuing to find ways to
strengthen the network.

Frieden et al (2017) note that the programmes aim to prevent a million events was easily
understood and resonated with diverse stakeholders, as did the concept of public health and
health care working together toward a common goal. The five year time frame gave a sense
of urgency and focusing on a limited set of proven, high-impact interventions helped partners
prioritize their efforts. Flexibility implementing interventions made diverse participation
possible.

Million Hearts supports individuals and organisations that are currently or aiming to put
resource into CVD prevention and encourage them to focus on implementing the ABCS and
other evidence based interventions that are likely to make a difference. “Waste no will” is a
key principle which leads to inclusivity of all organisations that have the goal of reducing the
risk factors that lead to CVD. This inclusivity results in diverse partners networking with each
other who may not otherwise have met.

Million Hearts® 2022

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The program is ongoing, with a second phase running from 2017 to 2022, committed to
preventing 1 million cardiovascular events over the period. Million Hearts® 2022 will focus
on improving the use of ABCS, participation in cardiac rehabilitation as well as reducing
tobacco use, sodium intake and promoting physical activity.

Ades et al (2016) outline a ‘road map’ to achieving 70% participation in cardiac rehabilitation
and secondary prevention programs by the year 2022. Current participation rates for cardiac
rehabilitation in the United States generally range from only 20% to 30%. The road map
focuses on interventions, such as electronic medical record–based prompts and staffing
liaisons that increase referrals of appropriate patients to cardiac rehabilitation services and
adherence to cardiac rehabilitation programmes. The authors calculate that increasing
cardiac rehabilitation participation from 20% to 70% would save 25,000 lives and prevent
180,000 hospitalizations annually in the United States.

Population
The Million Hearts program covers the whole of the US and the initial goal was to prevent a
million CVD events nationally, between 2012 and 2017.

Million Hearts 2022 identifies priority populations:

 Black/ African Americans with hypertension - improving hypertension control

 35 to 64 year olds - improving hypertension control & statin use and decreasing
physical inactivity
 people who have had a heart attack or stroke – increasing cardiac referral and
participation. Avoiding exposure to particulate matter
 people with mental and/ or substance use disorders - reducing tobacco use.

Service Delivery
The Million Hearts small core team is based in CDC where they:

 oversees partnerships with government

 develops surveillance, evaluation and research translation of effective interventions
 develops products such as the action guides, often in collaboration with external
partners
 supports partnerships and collaboration

Organisations can apply for funding from Million Hearts for short term projects to implement
an initiative that the organisation will sustain after this time. This funding is for innovative
projects that further the specific objectives of Million Hearts which include:

 encouraging health care teams to prioritise detection, treatment and control and
review data regularly to keep on track
 using technology that includes decision support, patient portals, registries, and
algorithms to find gaps in care
 processes around treatment protocols and the ABCS, proactive outreach and finding
patients with undiagnosed high BP, cholesterol or tobacco use
 patient and family supports – training in home BP monitoring, problem solving in
medication adherence, counselling on nutrition, physical activity, tobacco use,
referral to community-based physical activity programs and cardiac rehabilitation.

Partner organisations vary in size (from individual practices to large corporate organisations)
and health focus (from prevention to cardiac rehabilitation) so will deliver services differently
and on different scales.

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Outcomes
Data suggest that the Million Hearts initiative has made progress and will achieve about half
of its overall goal to prevent a million CVD events (events include emergency department
visits, hospitalizations, and deaths due to myocardial infarction, stroke, heart failure, and
related conditions).
Outcomes achieved through a combination of interventions and mechanisms include:
 Legislative change regarding trans-fat during 2018
 Guidance/ Voluntary Industry adoption of reduction of sodium in processed foods in
2016
 Embedding ABCS clinical quality measures in national reporting and performance
programs
 Introducing ‘competition’ that recognises achievements ABCS implementation with
‘Hypertension Control Champions’ (there were 24 in 2017).
 Better use of health tools and technology including financial incentive programs for
health care practices achieving meaningful use of electronic health records

The public, private and non-profit health sectors were encouraged to work together in a
coordinated way to achieve these targets and share goals.

In addition Million Hearts has been integrated into nursing and inter-professional educational
curricula and community settings (Gawlik et al 2015). The National Inter-professional
Education and Practice Consortium to Advance Million Hearts was created, and a free on-
line educational module was developed to help health care professionals and students learn
about the Million Hearts initiative, conduct community CVD risk factor screening, and refer
people who screen positive to appropriate resources. After completion of the module,
individuals receive certification as a Million Hearts Fellow. The module and CVD risk factor
screening has been incorporated into health sciences curricula. Academic institutions and
health science professions partnering together as part of the National Inter-professional
Education and Practice Consortium to Advance Million Hearts provide a unique opportunity
to demonstrate the impact that a unified approach can have on improving population health
through the use of screening, education, and prevention.

Primary prevention

Reduction in smoking: 7 million fewer people smoked cigarettes in 2015 than in 2011.

Reduction in sodium intake: Draft guidance to the food industry for voluntarily reducing
sodium in processed and commercially prepared food was issued in June 2016. This step
was intended to help Americans gradually reduce their sodium intake to the recommended
level of less than 2,300 mg per day, which will improve their blood pressure

Eliminate trans-fat intake: Partially hydrogenated oils were expected to be removed from the
food supply by 2018 with the intention of preventing thousands of fatal heart attacks every
year. Legislation passed in June 2015 required that within three years, all food prepared in
the US must not include trans-fats, unless approved by the Food and Drug Administration
(FDA). In May 2018 the FDA agreed to give companies one more year to find an alternative
ingredient.

Detection and management of CVD risk factors: ABCS implementation

ABCS clinical quality measures have been embedded in national reporting and performance
programs and performance in the ABCS has been rewarded e.g. the Million Hearts

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Hypertension Control Challenge – an annual competition that recognizes practices,
clinicians, and health systems that have achieved blood pressure control rates at or above
70%. Fifty-nine doctors, health care practices, and health systems serving more than 13.8
million patients had been recognized at the time that the ‘Final Report’ was written in 2016.

A focus on the ABCS has generated slow but steady improvement nationally in aspirin use,
blood pressure control, and statin use among people who are eligible based on current
guidelines. There is some variability in compliance with the ABCS quality measures and
there are opportunities for improvement (Eapen et al 2014).

Aspirin When Appropriate

 Data on aspirin use are from the National Health and Nutrition Examination Survey
(NHANES) and represent the self-reported use of aspirin among adults aged 40
years or older with a history of CVD. These data were not available before 2011–
2012
 In 2011–2012, aspirin use among adults aged 40 years or older with CVD was 81.1%
 There is need for improvement in some populations (e.g., non-Hispanic blacks:
70.4%; Hispanics: 65.4%; people aged 40–64 years: 71.3%)
 Actual 2013–2014 aspirin data will be available in 2017; actual 2015–2016 data will
be available in summer 2018.
Blood Pressure Control
 Blood pressure control among adults aged 18 years or older with hypertension is
monitored using NHANES, which measures population-level control. NHANES
participants include people who are not currently receiving medical care
 The Million Hearts® population-level target for blood pressure control is 65%. The
target for clinical settings is 70%.
 Population level blood pressure control has been improving slowly since at least
2005; it is projected to increase from 53.4% in 2009–2010 (Million Hearts® baseline)
to 57.7% in 2015–2016 (see Figure 1).

NHANES = National Health and Nutrition Examination Survey

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  Pockets of improvement to at least 70% have been demonstrated across diverse
clinical settings.

Young et al (2018) identified characteristics of health care practices and systems effective in
achieving control rates at or above 70% by using data collected via applications submitted
from April through June 2017 for consideration in the Million Hearts Hypertension Control
Challenge.

They included 96 practices serving 635,000 patients with hypertension across 34 US states
in the analysis. Mean hypertension control rate was 77.1% with 27.1% of practices having a
control rate of 80% or greater. Although many practices served large populations with
multiple risk factors for uncontrolled hypertension, high control rates were achieved with
implementation of multiple evidenced-based strategies.
There were some factors common to these practices including:
 Using multiple strategies to achieve high BP control rates aligned with the World
Health Organization’s Innovative Care for Chronic Conditions recommendations, and
strategies recommended by the Centers for Disease Control and Prevention funded
State Public Health Actions grantees and Million Hearts.
 Having electronic health records with features such as electronic prescribing, patient
registries, and clinical decision support tools
 Implementing hypertension treatment protocols. This helps standardize and
coordinate care and facilities a team approach to BP management
 Some practices were offered financial and other incentives to clinicians and patients
to encourage greater attention to BP control by health insurers
 Engaging patients in BP home monitoring to assess progress, inform decision
making, and encourage adherence to treatment regimens
Freidan et al (2017) >125,000 physicians who were part of the electronic health records
Medicare incentive programme reported an average blood pressure control rate of 62%
across >17 million people with hypertension.

Cholesterol Management
 In 2013, the American College of Cardiology (ACC) and the American Heart
Association (AHA) released new clinical guidelines on the treatment of blood
cholesterol to reduce atherosclerotic CVD (ASCVD) risk in adults.
 The new guidelines focus only on statin use in (1) adults with clinical ASCVD, (2)
adults with LDL ≥190 mg/ dL, (3) adults aged 40–75 years with type 1 or 2 diabetes,
and (4) adults aged 40–75 years with an estimated 10-year ASCVD risk of at least
7.5%.
 A federal workgroup drafted a new “Statin Therapy for the Prevention and Treatment
of Cardiovascular Disease” measure. This measure assesses statin use among the
first three of the four risk groups (see above bullet point) and will be available during
2018 for electronic health record reporting.
 Retrospective analysis reflecting statin use among all four groups of eligible people,
using 2005–2012 NHANES data, show that statin use has been steadily on the rise
since at least 2005–2006 (see Figure 2).

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NHANES = National Health and Nutrition Examination Survey

Smoking Prevalence—Combustible Tobacco

 The use of combustible tobacco products, including cigarettes, cigars, and pipes, is
monitored in the Substance Abuse and Mental Health Services Administration’s
(SAMHSA’s) National Survey on Drug Use and Health (NSDUH).
 Combustible tobacco use has been declining since at least 2005–2006 and is
projected to surpass the Million Hearts® target of 23.6% by 2017 (see Figure 3).

NSDUH = National Survey on Drug Use and Health

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Sodium Intake
 Mean sodium intake (mg/day) among adults aged 18 years or older is estimated
using NHANES dietary intake data.
 Mean daily sodium intake has decreased slightly since 2005, but during Million
Hearts®, the values have levelled off (see Figure 4). In 2011– 2012, mean daily
sodium intake was highest among adults aged 18–44 years (3,907 mg/day) and men
(4,255 mg/day). The Million Hearts® target is a 20% reduction from the 2009–2010
mean daily sodium intake (~2,900 mg/day).

NSDUH = National Survey on Drug Use and Health

Health Tools and Technology: Electronic Health Record (EHR) Incentive Programs
rewarded health care practices for achieving meaningful use of EHRs. Use of EHRs for
outpatient care increased from 34% in 2011 to 87% in 2015. Health information technology
has helped identify more than half a million people who may have hypertension.

Leadership and Governance

The US Department of Health and Human Services established Million Hearts. The initiative
is co-led by the Centers for Disease Control and Prevention and the Centers for Medicare
and Medicaid Services.

Organizations can apply to be partners through the Million Hearts website and a range of
resources are available providing platforms of communication and shared learning. The
Million Hearts network is comprised of a core group of federal and private sector partners
that regularly participate in Million Hearts activities.

Varda et al (2018) conducted a social network analysis. This too analysed how partners are
connected, how resources are exchanged, the levels of trust and perceived value among

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partners and links between the outcomes and the process of collaboration, and other more
customized questions were added for the Million Hearts project. The analyses show a
network that is decentralized, has strong perceptions of trust and value among its members,
and strong agreement on intended outcomes. Interestingly, partners report a desire and
ability to contribute resources to

The perceptions between partners are that resources are not being contributed at the level
they potentially could be. The majority of partners reported that being in the network helped
them achieve their goals related to cardiovascular disease prevention. The largest barrier to
successful activities within the network was cited as lack of targeted funding and staff to
support participation in the network. However the network is unique in its membership at the
national level, agreement on outcomes, information-sharing abilities that require few
resources. It has a decentralized structure, with a core team identifying ways to strengthen
the network.

Finances
The core team, funded through CDC that works to distribute funding and support networks of
partners, and information gathering.

Organisations can apply for funding from Million Hearts for short term projects to implement
an initiative that the organisation will sustain after this time. This funding tends to be for
innovative projects such as helping health centres use their clinical data to identify potentially
hypertensive patients, or work to improve numbers of people monitoring their own blood
pressure.

Partners join the network because they have a common aim to reduce the risk of CVD and
take part in challenges, apply for funding, receive incentives from medical insurers or
voluntarily develop services to meet the Million Hearts goals.

Human Resources
The core team comprise:

 An Executive Director is supported by an advisor who oversees partnerships with

government.
 A Science Lead focuses on surveillance, evaluation and research translation.
 A team that develops products such as the action guides, often in collaboration with
external partners.
 A team supporting partnerships and collaboration

Knowledge and Information

A key strategy is agreement by all partners that the same performance measures should be
used if possible and this has largely been achieved in relation to the ABCS as well as the
population level assessment of sodium and tobacco prevalence.

Population level surveys are utilised, and though accurate may not be timely for the
purposes of Million Hearts. The Million Hearts team tend to ‘amass data patches’ from
health systems and local data in order to build a national picture. There are national
surveillance data systems that are pieced together for various intermediate and long term
indicators. There is a small set of clinical indicators that Million Hearts have worked to

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embed in federal, national and private reporting initiatives and it is these that Million Hearts
looks at. Clinicians are reporting to those systems, not necessarily for Million Hearts but
because there are financial incentives to submitting the data– some of the impetus is from
quality and payment systems. Those systems are looked at and pieced together to build a
national picture.

On occasion a clinic or local health system may look at their data and choose to share it with
Million Hearts and this is encouraged by, for example, the Champion Program for blood
pressure.

Often spontaneous regional public health/health care collaborations arise using the Million
Hearts framework. There is confidence in using framework developed by an independent
government agency and there is flexibility about what to implement for their particular
population.

REFERENCES
 Ades PA. Keteyian SJ. Wright JS. Hamm LF. Lui K. Newlin K. Shephard DS. Thomas
RJ. Increasing Cardiac Rehabilitation Particpation from 20% to 70%: A Road Map
From the Million Hearts Cardiac Rehabilitation Collaborative. Mayo Clin Proc. 2017
February ; 92(2): 234–242. doi:10.1016/j.mayocp.2016.10.014.
 Eapen ZJ. Liang L. Shubrook JH. Bauman MA. Bufalino VJ. Bhatt DL. Peterson ED.
Hernandez AF. Current Quality of Cardiovascular Prevention for Million Hearts: An
Analysis of 147,038 Outpatients from The Guideline Advantage. American Heart
Journal. 2014,Volume 168, Number 3.
 Frieden TR. Wright JS. Conway PH. Is Rapid Health Improvement Possible?
Lessons From the Million Hearts Initiative. 2017;135:1677–1680. DOI:
10.1161/CIRCULATIONAHA.117.027461
 Gawlik KS. Melnyk BM. Integrating Million Hearts Into Nursing and Interprofessional
Educational Curricula and Community Settings: A Key Strategy for Improving
Population Health Across the United States. Journal of Professional Nursing, Vol 31,
No. 2 (March/April), 2015: pp 112–118
 Varda DM. Williams MV. Schooley M. Duplantier D. Newman K. Lowe Beasley K.
Lucido B. Marshall A. An Innovative Network Approach to Coordinating a National
Effort to Improve Cardiovascular Health: The Case of Million Hearts. 2018 (epub
ahead of print)
 Young A. Ritchey MD. George MG, Hannan J. Wright J. Characteristics of Health
Care Practices and Systems That Excel in Hypertension Control. Preventing Chronic
Disease 2018;15:170497. DOI: https://doi.org/10.5888/pcd15.170497.

International CVD Prevention Case Study Report Page | 153

9 References

1
Public Health England Action Plan for CVD prevention 2017 and 2018 September 2017
London
2
Wilkins E, Wilson L, Wickramasinghe K, Bhatnagar P, Leal J, Luengo-Fernandez R, Burns
R,Rayner M, Townsend N (2017). European Cardiovascular Disease Statistics 2017.

European Heart Network, Brussels. For exchange rate conversions, see Eurostat database
http://ec.europa.eu/eurostat/data/database (accessed 27.02.2018)
3
Public Health England Action Plan for CVD prevention 2017 and 2018 September 2017
London
4
Wilkins E, Wilson L, Wickramasinghe K, Bhatnagar P, Leal J, Luengo-Fernandez R, Burns
R,Rayner M, Townsend N (2017). European Cardiovascular Disease Statistics 2017.
European Heart Network, Brussels. For exchange rate conversions, see Eurostat database
http://ec.europa.eu/eurostat/data/database (accessed 27.02.2018)
5
Van Olmen J, Criel B, Van Damme W, et al. Analysing Health System Dynamics: A
framework. Studies in Health Services Organisation and Policy 28. 2nd edition, 2012
6
Scarborough P, Wickramasinghe K, Bhatnagar P, Rayner M (2011) Trends in coronary
heart disease 1961 to 2011. British Heart Foundation, London.
7
Jones D, Greene J (2013) Decline and rise of Coronary Heart Disease American Journal of
Public Health vol 103 no 7 pp1207-1218
8
Capewell S, Morrison CE, McMurray JJ. (1999) Contribution of modern cardiovascular
treatment and risk factor changes to the decline of coronary heart disease mortality in
Scotland between 1975 and 1994. Heart 81:4, 380-386.
9
Cooper R et al (2000) Trends and disparities in coronary heart disease, stroke and other
cardiovascular disease in the United States: Findings of the National Conference on
Cardiovascular Disease Prevention Circulation 102 3137-3147
8
E. S. Ford and S. Capewell, “Coronary Heart Disease Mortality Among Young Adults in the
US From 1980Through 2002: Concealed Leveling of Mortality Rates,” Journal of the
American College of Cardiology 50, no. 22 (2007): 2128–2132, on pp. 2128, 2131.
11
Jones D and Greene J The decline and rise of coronary heart disease; Understanding Public Health
Catastrophism Am J Public Health. 2013;103:1207–1218
12
Public Health England Action Plan for CVD prevention 2017 and 2018 September 2017
London
13
National Health Service 2017 Next steps on the Five Year Forward View March 2017
London

International CVD Prevention Case Study Report Page | 154

14
Matt Kearney Preventing Heart Attacks, Strokes and Dementia NHS England (2017)
https://www.england.nhs.uk/blog/preventing-heart-attacks-strokes-and-dementia-the-size-of-
the-prize-for-stps/ (accessed March 7th 2018)
15
Bronfenbrenner, Urie (1989). "Ecological systems theory". In Vasta, Ross. Annals of Child
Development: Vol. 6. London, UK: Jessica Kingsley Publishers. pp. 187–249
16
White F. Primary health care and public health: foundations of universal health systems.
Med Princ Pract 2015;24:103-116. doi:10.1159/00037
17
Vale MJ. Jelinek MV. Best JD. Dart AM. Grigg LE. Hare DL. Ho BP. Newman RW. McNeil
JJ. Coaching patients on achieving cardiovascular health (COACH): a multicenter
randomized trial in patients with coronary heart disease. Arch Intern Med 2003, 163(22):
2775-2783
18
Vale MJ. Sundararajan V. Jelinek MV. Best JD. Four-year follow-up of the multicenter
RCT of Coaching patients On Achieving Cardiovascular Health (The COACH study) shows
that the COACH Program keep patients out of hospital. Circulation 2004 110: suppl. III-801
19
Pouchain et al.: Effects of a multifaceted intervention on cardiovascular risk factors in
high-risk hypertensive patients: the ESCAPE trial, a pragmatic cluster randomized trial in
general practice. Trials 2013 14:318.
20
Vernooij JWP. Kaasjager HAH. van der Graaf Y. Wierdsma J. Grandjean HMH. Hovens
MMC. de Wit GA. Visseren FLJ. On behalf of the SMART study group. Internet based
vascular risk factor management for patients with clinically manifest vascular disease:
randomised controlled trial. BMJ 2012, 344: e3750
21
Greving JP. Kaasjager HAH. Vernooij JWP. Hovens MMC. Wierdsma J. Grandjean HMH.
van der Graaf Y. de Wit GA. Visseren FLJ. Cost-effectiveness of a nurse-led internet-based
vascular risk factor management programme: economic evaluation alongside a randomised
controlled clinical trial. BMJ Open 2015, 5: e007128
22
Ye C. Foster G. Kaczorowski J. Chambers LW. Angeles R. Marzanek-Lefebvre F. Laryea
S. Thabane L. Dolovich L. The impact of a cardiovascular health awareness program
(CHAP) on reducing blood pressure: a prospective cohort study. BMC Public Health 2013,
13: 1230
23
Kaczorowski J. Chambers LW. Dolovich L. Paterson JM. Karwalajtys T. Gierman T. Farrell
B. McDonough B. Thabane L. Tu K. Zagorski B. Goreree R. Levitt CA. Hogg W. Laryea S.
Carter MA. Cross D. Sabaldt RJ. Improving cardiovascular health at population level: 39
community cluster randomised trial of Cardiovascular Health Awareness Program (CHAP).
BMJ 2011, 342:d442
24
Nakao YM, Miyamoto Y, Ueshima K ,Nakao K, Nakai M, Nishimura K, et al. (2018)
Effectiveness of nationwide screening and lifestyle intervention for abdominal obesity and
cardiometabolic risks in Japan: The metabolic syndrome and comprehensive lifestyle
intervention study on nationwide database in Japan (MetSACTION-J study). PLoS ONE
13(1): e0190862.https://doi.org/10.1371/journal.pone.0190862

International CVD Prevention Case Study Report Page | 155

25
Record NB. Onion DK. Prior RE. Dixon DC. Record SS. Fowler FL. Cayer GR. Amos CI.
Pearson TA. Community-wide cardiovascular disease prevention programs and health
outcomes in a rural community, 1970-2010. JAMA 2015, 313(2): 147-155
26
Sidebottom AC. Sillah A. Miedema MD. Vock DM. Pereira R. Benson G. Boucher JL.
Knickelbine T. Lindberg R. VanWormer JJ. Changes in cardiovascular risk factors after 5
years of implementation of a population-based program to reduce cardiovascular disease:
The Heart of New Ulm Project. American Heart Journal 2016, 175: 66-76
27
Ade P, Kottke T, Houston Miller N, McGrath J, Record B, Record S, Task Force #3—
Getting Results: Who, Where, and How? JACC Vol. 40, No. 4, 2002. 579–651
28
Institute for Voluntary Action Research (IVAR) and Social Enterprise UK. Building Healthy
Partnerships. Briefing one; Improving self care at a local level (2018) IVAR, London
https://www.ivar.org.uk/wp-content/uploads/2018/03/IVAR020-BHP-Findings-mini-report_V6.pdf

International CVD Prevention Case Study Report Page | 156